Failure to Follow Two-Assist Bed Mobility Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to implement required fall-prevention interventions and provide adequate supervision during bed mobility for one resident. The resident had diagnoses including morbid obesity, heart failure, and muscle weakness, and the MDS documented a need for substantial/maximal assistance to roll left and right. The resident’s care plan, initiated earlier in the year, identified the resident as at risk for injury related to falls due to decreased mobility and generalized weakness and specified that two-person assistance was required for transfers and bed mobility. On the day of the incident, the resident was being provided incontinence care by a CNA. The CNA reported sliding the resident toward herself and then rolling the resident slightly toward the window, leaving the resident slightly turned onto her right side. At that point, the CNA left the bedside to go to the bathroom to obtain a washcloth, towel, and soap, leaving the resident unattended in a partially turned position. While the CNA was in the bathroom, the resident fell from the bed to the floor. Progress notes documented that the resident was found on the floor lying on her back, alert and oriented, with bleeding noted from a pre-existing left leg wound and later complaining of pain in the head area. The facility’s investigation determined 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. The unit assignment sheet in use that day also indicated that the resident required two-person assistance for bed mobility, and in interview the CNA acknowledged receiving the assignment sheet but not recognizing the two-assist requirement for bed mobility, despite knowing the resident required two-person assistance for transfers.
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