Failure to Follow Two-Person Assist Requirement During Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to provide ADL care and services in accordance with a resident’s assessed needs and care plan, specifically related to safe bed mobility and transfers. The resident was admitted with significant medical conditions including anoxic brain damage, tracheostomy status, and gastrostomy status, and had been assessed as totally dependent for self-care and mobility. A Fall Risk Evaluation showed a high fall risk score of 11, and the resident’s care plan for Activities of Daily Living documented that the resident required total assistance for ADLs, was non-ambulatory, and that the resident’s wife preferred a two-person assist for bed mobility, transfers, and getting out of bed. The MDS Section GG further indicated a score of 1 for self-care and mobility, meaning the resident was dependent and required the assistance of two or more helpers to complete activities. Despite these assessments and care plan directives, on the morning of November 8, 2025, a CNA provided incontinence care and repositioned the resident in bed alone, without a second staff member. The CNA reported that he was working alone due to a lack of assistance and the impending end of his shift, and acknowledged that protocol required a two-person assist for this total-care resident. He noted the resident was very close to the edge of the bed and, when he turned the resident onto his side, the resident fell from the bed. Nursing notes documented that the CNA informed the charge nurse that the resident was on the floor, and that the resident was subsequently sent to the hospital after a witnessed fall, with three sets of abnormal vital signs recorded (BP 79/66, pulse 124, oxygen saturation 85%). The facility’s ADL policy stated that appropriate care and services are to be provided for residents unable to carry out ADLs independently, in accordance with the plan of care, which was not followed in this incident.
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