Failure to Follow Bed Mobility Care Plan Resulting in Resident Fall from Bed
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not following the resident’s care plan for bed mobility and by leaving the resident unattended in an unsafe position. The facility’s abuse/neglect policy defined neglect as the failure to provide goods and services necessary to avoid or that may result in physical harm, pain, mental anguish, or emotional distress. The resident involved had diagnoses including morbid obesity, heart failure, and muscle weakness, and the MDS indicated the resident required substantial/maximal assistance to roll left and right. The resident’s care plan and unit assignment sheet specified that the resident required assistance of two staff for transfers and bed mobility due to decreased mobility and generalized weakness and being at risk for injury related to falls. On the day of the incident, the resident experienced a fall from bed during care. A progress note documented that the ADON was called to the unit regarding a fall from bed and found the resident on the floor lying on her back, alert and oriented and able to answer questions. Another progress note recorded that the resident complained of pain in the head area, 911 was called, and the resident remained on the floor until paramedics arrived. The emergency department physician later documented that the resident presented after a fall out of bed with head injury and was complaining of pain in the head, neck, shoulder, and back, and had bleeding through the bandages on a chronic left wound. Facility documentation and staff statements showed that a nurse aide provided incontinence care alone, despite the care plan and assignment sheet indicating a two-person assist for bed mobility. The aide reported sliding and partially rolling the resident, then leaving the resident slightly turned on her side to go to the bathroom to obtain a washcloth and towel. While the aide was in the bathroom, the resident fell from the bed. The facility’s investigation concluded that the CNA failed to follow the resident’s plan of care requiring two-person assistance for bed mobility and walked away from the resident while she was slightly turned, which resulted in the resident falling out of bed and sustaining injury, including bleeding from a prior wound and complaints of neck pain.
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