F0689

G

Resident Fall From Bed Due to Inadequate Assistance and Inaccurate Care Plan for Bed Mobility

Milwaukee, Wisconsin Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s environment was as free of accident hazards as possible and that adequate supervision and assistance were provided during bed-level care. The resident had multiple diagnoses, including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, syringomyelia, COPD, depression, anxiety, hypertension, and chronic respiratory failure. On both a significant change MDS and a subsequent quarterly MDS, the resident was assessed as "dependent" for bed mobility, which, per the RAI Manual and staff interviews, means the helper does all of the effort and that two or more helpers are required for safe completion of the activity. Therapy documentation from several months also described the resident as dependent in all bed mobility, and staff interviews confirmed the resident could not turn or reposition independently.

Despite these assessments, the resident’s care plan, initiated months earlier and not revised, documented that the resident required the assistance of one staff for bed mobility and the use of half bed rails bilaterally for repositioning and bed mobility. A side rail assessment later identified a bed bar/enabler bar as the device in use, and the facility reported that it does not use side rails, only a small horseshoe-shaped grab bar. The care plan was therefore not reflective of the current MDS assessments or the resident’s actual level of assistance needed. The MDS nurse stated that a dependent code requires two-person assist per CMS guidelines and acknowledged that if the care plan indicated one-person assist, then the care plan was not updated or correct. The DON and PTA also stated that being dependent for bed mobility means the resident would require two-person assistance, and staff reported that after the fall the resident was always treated as a two-person assist for bed mobility.

The fall event occurred when a CNA was providing in-bed care to the resident in preparation for a shower. The CNA raised the bed to working height and turned the resident onto his right side, away from herself, while the bed was slightly angled per the resident’s preference. The resident, who had left-sided hemiplegia and could not use the grab bar with the affected side, experienced an arm spasm that stopped, and then the CNA reached for a towel placed on the wheelchair next to her. During this moment, the CNA did not maintain control of the resident, and he continued to roll and slid out of bed onto the floor. The CNA reported she was unable to stop him from rolling as it happened quickly. The facility’s own education materials on safe in-bed care emphasized maintaining one-hand contact during turning, not leaving residents unattended on a raised bed, and standing on the side toward which the resident could roll if side rails are not used. The investigation summary stated the facility believed the care plan was followed and did not submit a self-report, but surveyor review concluded that the resident, assessed as dependent for bed mobility, was provided care with only one staff, rolled away from the caregiver, and not adequately controlled, resulting in a fall with head laceration requiring sutures and a questionable rib fracture.

Interviews with nursing and therapy staff further clarified the mismatch between documentation and practice. The DON acknowledged that the resident was dependent for bed mobility and could not turn or reposition himself, yet stated that therapy had determined he was a one-person assist, even though therapy notes did not specify this and instead documented dependency. The PTA confirmed the resident could not roll himself at all and was dependent for bed mobility, meaning two-person assist. A CNA reported that before the fall she would roll the resident by herself and that after the hospital return he was always treated as a two-person assist. The NHA disputed that the definition of dependent necessarily required two-person assist, but the surveyor referenced the RAI Manual and staff statements indicating that dependent status includes the need for two helpers for safe completion of the activity. These inconsistencies in assessment, care planning, and actual care practices contributed to the resident being turned and cared for in bed by a single CNA, rolled away from the caregiver, and left without continuous physical control on a raised bed, culminating in the fall and injury.

The facility’s investigation summary stated that the bed locks were in proper working order and that this was the resident’s first fall since admission. However, the surveyor noted that the resident’s MDS assessments, therapy documentation, and staff interviews consistently described him as dependent for bed mobility, while the care plan and actual staffing during the incident reflected only one-person assistance. The surveyor also highlighted that the resident was turned onto his right side, leaving his hemiplegic left side exposed and unable to utilize the bed bar, and that the CNA rolled him away from herself contrary to external guidance on dependent rolling techniques, which recommend positioning on the side toward which the resident is to roll and rolling the resident toward the caregiver. These documented actions and discrepancies formed the basis of the deficiency for failure to maintain a hazard-free environment and provide adequate supervision and assistance devices to prevent accidents.