Failure to Follow Bed-Mobility Care Plan Leads to Fall and Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident safety and to implement care-planned interventions during staff-assisted care, resulting in a resident falling from an elevated bed and sustaining a serious leg laceration. The resident was an older female with chronic heart failure, diabetes, morbid obesity, major depression, and anxiety disorder. Her MDS showed a BIM score of 11, indicating moderately impaired decision-making, and documented that she was dependent on staff for toileting, dressing, bathing, and rolling in bed. Her care plan, dated 1/2/26, specified that she had a functional ability deficit related to morbid obesity and weakness, and required a two-person assist for all aspects of bed mobility, including rolling side to side. On the morning of the fall, a CNA was providing incontinence care to the resident and rolled her away from herself while the bed was elevated to between knee and hip height. During this maneuver, the resident fell out of the bed to the floor and began screaming in pain. Another CNA and a nurse responded and observed the resident lying face down on the floor next to the elevated bed, with blood pooling under her right knee and a large open wound on her right lower leg. The resident complained of back and leg pain. Emergency services were called, and the resident was transported to the hospital, where she was treated for a significant laceration of the right lower leg requiring 24 sutures and placement of internal drains. Record review showed that the resident’s care plan required a two-person assist for bed mobility, but the CNA who provided care at the time of the fall believed the resident was an assist of one based on the Kardex and did not verify this information. The CNA reported that she had completed a written witness statement and was later educated to follow the Kardex and to roll residents toward, not away from, herself during care. However, the administrator and DON were unable to produce any written witness statements as part of the facility’s investigation, and the investigation materials provided did not include such documentation. The DON acknowledged that the facility failed to follow the care-planned interventions for two-person assist with bed mobility, which led to the resident’s fall with injury, and stated that staff were expected to follow care plans and Kardex and to roll residents toward themselves during in-bed care.
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