Failure to Provide Required Two-Person Assist for Bed Mobility Resulting in Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received required two-person assistance for bed mobility, resulting in an avoidable accident and injury. The resident had diagnoses including aphasia following cerebral infarction and encephalopathy, and chronically received anticoagulant medication for valvular atrial fibrillation. Her Activities of Daily Living care plan, revised on 03/22/2023, and her quarterly MDS dated 12/26/2025 both documented that she was dependent on two or more helpers for bed mobility, including rolling and repositioning in bed. On the date of the incident, a nursing progress note documented that the resident fell from the bed, hit the back of her head, sustained a 2 cm laceration, and was sent to the hospital for further evaluation. Hospital records showed that she presented to the emergency department after a fall from bed at the SNF and was found to have a new left frontal intraparenchymal hemorrhage that increased slightly in size on a four-hour repeat CT scan, with increased ventricular size compared to a prior scan from 2019. A nurse practitioner stated that, based on the notes, after the fall the resident was found to have new bleeding in the brain and that the ventricles had increased in size, showing swelling to the brain, and that her anticoagulant medication was held because it can cause bleeding. The facility’s investigation and staff interviews showed that the CNA providing care repositioned the resident in bed without obtaining the required second person assist and did not adjust the bed position before attempting the task. The CNA reported noticing the resident at the edge of the bed, pushing her upper body toward the middle, then moving to the opposite side and using the draw sheet to pull her, without lowering the head of the bed or using bed controls, and without calling for help until after the resident slid off the bed. The CNA acknowledged that the incident could have been prevented if another staff member had been present to assist and act as a barrier. The weekend nurse manager and the DON both confirmed that the resident required two-person assistance for bed mobility per her plan of care, that staff were expected to follow this plan, and that the fall was an avoidable accident because the CNA did not obtain a second person to assist.
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