Improper Bed Mobility Assistance Leading to Resident Fall From Bed
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper positioning and bed mobility assistance during ADL care, resulting in a resident sliding out of bed and requiring hospital transfer. The resident had been admitted with a nondisplaced trimalleolar fracture of the right ankle, a fracture of the shaft of the right fibula, and an anxiety disorder, and had a BIMS score of 10/15 indicating moderately impaired cognition. The resident’s ADL care plan specified that he required one-person extensive assistance by staff for bed mobility, including turning and repositioning while in bed. During an episode of incontinence care, the CNA instructed the resident to roll to his left side; in the process, he slid off the bed while still on top of the mattress and ended up on the floor. According to the nurse’s note and subsequent interview, the resident reported that when he began sliding off the bed and told the CNA he was falling, she did not assist him. The LPN stated that when he arrived at the room, the resident was half in and half out of the bed and that the resident then assisted himself back onto the bed. The resident later contacted an outside party and reported that he had soiled himself, could not get help, and that after he fell, the aide lowered the bed and told him he could crawl back into bed himself, which he did. The facility’s Administrator stated that their investigation concluded the incident resulted from improper bed mobility technique and insufficient positioning safeguards during care.
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