Failure to Specify Bed Mobility Assistance Level in Care Plan Resulting in Fall Injury
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with clear, measurable objectives and time frames for a resident’s bed mobility needs. The resident was an older female with multiple significant diagnoses, including cerebral infarction with hemiplegia/hemiparesis on the left non-dominant side, lack of coordination, reduced mobility, osteoporosis, muscle weakness, and a prior displaced comminuted fracture of the left femur. Her comprehensive MDS showed intact cognition (BIMS 14) and documented that she was dependent on staff for rolling left and right, with the helper doing all of the effort or requiring assistance of two or more helpers. The care plan and Kardex, however, only stated that she required “staff assistance” for bed mobility and did not specify whether she required a 1‑person or 2‑person assist. On the date of the fall, the resident’s care plan included problem areas such as ADL self‑care performance deficit related to functional decline and contractures, positioning support devices (HALO and 1/4 siderails), and risk for falls related to history of falls, hypotension, and generalized weakness. Interventions for bed mobility stated only that she required staff assistance for bed mobility (rolling left and right, sit to lying, lying to sitting), without clarifying the number of staff needed. The MDS and Kardex were based on section GG and also reflected that she was dependent for toileting, showering/bathing, and rolling, but again did not distinguish between 1‑person and 2‑person assist. Interviews with the MDS Coordinator, MDS Resource Coordinator, and DON confirmed that the facility’s practice was to interpret “staff assistance” as 1‑person assist, with the number of staff informally adjusted depending on the CNA’s strength and the resident’s condition on a given day, rather than being explicitly defined in the care plan. During the incident, a CNA provided a bed bath and incontinent care to the resident using the mobility bar (HALO). The CNA reported that after completing the bed bath, she positioned the resident on her right side, with the resident holding the mobility bar, and asked the resident multiple times if she had a firm grasp. As the CNA placed an adult brief under the resident, the resident rolled off the bed and landed on her left side. Progress notes documented that the resident fell from the bed while using the mobility bar, with vital signs stable and initial complaints of pain to the left side. Subsequent notes showed ongoing complaints of bilateral leg, knee, and ankle pain, and imaging eventually revealed a comminuted, mildly impacted, intra‑articular fracture of the distal left femur, requiring a leg immobilizer. The resident later stated that sometimes one staff member and sometimes two staff members assisted her with bed baths and incontinent care, and that the aide involved in the fall was not following protocol. Facility leadership acknowledged that the Kardex and care plan did not specify 1‑person versus 2‑person assist and that aides were expected to infer this from the generic “staff assistance” designation.
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