Failure to Implement and Update Bed Mobility Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to implement and update a comprehensive care plan for a resident whose needs had changed. The resident had chronic respiratory failure with hypoxia, heart failure, and venous insufficiency, and was assessed on the Minimum Data Set as being dependent for ADLs including bed mobility, transfers, locomotion, and toileting, though able to communicate needs clearly. The care plan identified an ADL self-care deficit and directed that bed mobility be performed with assistance of two to three staff and the use of a bed pad. Facility documentation showed that during care on January 28, 2026, NA 1 observed a bruise on the resident’s left forearm. Further review revealed that NA 2 had used the resident’s left forearm to roll the resident toward him, and there was no evidence that a second staff member was present or that a bed pad was used, contrary to the existing care plan. In an interview, the resident stated she could reposition in bed with the assistance of one staff member and a bed pad, and the DON confirmed that the bed pad was not used and that the care plan did not reflect the resident’s current bed mobility status requiring assistance of one staff with a bed pad.
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