Failure to Provide Required Two-Person Assistance During Bed Mobility Resulting in Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate physical assistance with bed mobility to a resident who required two-person assistance, resulting in a fall from bed and a leg fracture. The resident had diagnoses including Parkinson’s disease, hereditary and idiopathic neuropathy, cerebrovascular disease, spondylosis, degenerative disease of the nervous system, and fibromyalgia. An MDS assessment showed the resident was cognitively intact but required substantial/maximal assistance for rolling in bed and returning to a lying position, and a fall risk assessment identified the resident as being at moderate risk for falls. The resident’s care plan documented a risk for ADL decline related to impaired mobility and specified that two staff were to assist with all bed mobility, turning, and repositioning for comfort. On the date of the incident, a CNA entered the resident’s room and changed the bed sheet while the resident remained in bed, performing this task alone despite the care plan requirement for two-person assistance with bed mobility. The CNA rolled the resident to the left side of the bed, away from herself, to change the sheet. While the CNA was changing the sheet, she observed the resident holding onto the bed rail but continued the task. The CNA later saw the resident fall from the bed; she reported that the bed was in a high position at the time the resident fell. Following the fall, an RN was called to the room by the CNA and found the resident in pain. The RN assessed the resident, and the resident requested to be sent to the hospital rather than have an X-ray performed at the facility. The RN contacted the primary care physician, who agreed to send the resident to the hospital. The facility’s investigation confirmed that the CNA was alone in the room during the bed sheet change, contrary to the resident’s care plan requiring two staff for bed mobility. The DON stated she was informed that the resident had sustained a leg fracture as a result of the fall, although specific details of the injury were not documented in the investigation summary.
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