F0689

G

Failure to Follow Two-Person Assist Requirements During Bed Mobility Resulting in Fall and Head Laceration

Hingham, Massachusetts Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident who required the assistance of two staff members for bathing, dressing, and bed mobility was provided with that level of assistance during care, resulting in a fall and injury. The facility had policies on Fall Management and on Lifting, Transfer and Bed Mobility that required residents to be assessed for mobility needs, have individualized care plans, and have the type and level of assistance (including number of staff required) communicated to staff and reflected in the care plan and care card. For this resident, the care plan and resident care card both specified total dependence with assistance of two staff members for bathing, dressing, and bed mobility. The resident’s MDS assessment documented severe cognitive impairment (BIMS score of 00) and dependence on staff for these ADLs.

On the date of the incident, a care associate assigned to the resident provided morning care and repositioning while the resident was in bed. The care associate reported that she turned the resident onto his/her back, put pants on up to the ankles, then turned the resident toward her near the edge of the bed and began to pull up the pants. At that point, the resident slid off the bed and landed face down on the floor. The care associate stated that the resident hit his/her head on the floor and began bleeding from above the right eyebrow. She immediately applied pressure with a towel and called out for help. The nurse on duty heard the call for help, went to the room, and found the resident lying face down on the floor near the bed with profuse bleeding from a laceration above the right eyebrow.

The nurse assessed the resident, applied pressure to the laceration, and emergency protocols were initiated, with the resident transferred to the hospital ED. Hospital documentation indicated the resident presented after a fall at the facility with a 2.5 cm laceration to the right forehead that required closure with seven sutures. In interviews, the care associate acknowledged she knew the resident required two staff members for bed mobility and in-bed care but provided care alone and did not request assistance. The nurse and the DON both confirmed that the resident required two-person assistance for bathing, dressing, and bed mobility as indicated on the care plan and care card, and that only one staff member was present in the room at the time of the incident. The DON stated that the care associate did not follow the resident’s care plan, resident care card, or facility policy, leading to the incident in which the resident slid from the bed to the floor and sustained a head laceration.

The facility’s Fall Management policy defined a fall as any event resulting in the resident coming to rest unintentionally on the floor or a lower level when found on the floor, and required assessment of residents for fall risk and development of individualized care plans with fall prevention protocols. The Lifting, Transfer and Bed Mobility policy required that bed mobility be assessed as one-person or two-or-more-person assist, and that the type and level of assistance, including number of staff required for bed mobility and transfers, be communicated to staff and reflected in the care plan. Despite these policies and the documented requirement for two-person assistance, the resident was turned and repositioned near the edge of the bed by a single care associate, which directly preceded the resident sliding off the bed and sustaining the injury.