F0689

G

Failure to Provide Clear, Resident-Specific Assistance Levels for Bed Mobility and Bedpan Use Resulting in Fall with Fracture

Keokuk, Iowa Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide clear, resident-specific directions to staff regarding the level of assistance required for bed mobility and use of a bedpan for a dependent resident, which resulted in a fall with fracture. The resident had intact cognition with a BIMS score of 15, and diagnoses including hereditary motor and sensory neuropathy, COPD, and chronic respiratory failure with hypoxia. The MDS identified the resident as non-ambulatory, using a wheelchair for mobility, and dependent for rolling and bed-to-chair transfers. ADL documentation around the time of the incident was inconsistent: one entry described the resident as an extensive two-person assist with bed mobility, another documented assist of 1–2 staff for toileting, and another documented assist of 2 for bed mobility but also stated the resident was independent with repositioning. Prior to the fall, the care plan addressed fall risk and limited physical mobility but did not clearly specify the number of staff required for repositioning and toileting.

On the day of the fall, a CNA assisted the resident with use of a bedpan. The CNA reported asking the resident to roll to his side and observed him attempting to grab the assistance rail; during this process, his legs slid off the bed, causing the rest of his body to follow and he slid to the floor. The nurse responding to the call found the resident on his back on the floor beside the bed with external rotation and visible deformity of the left leg and inability to move it. Hospital records later confirmed a left femur fracture resulting from a fall out of bed. The facility’s self-report stated that at the time of the event, only one staff was required for assisting the resident with repositioning in bed, and that the CNA was following those expectations.

Multiple staff interviews revealed inconsistent understanding and communication regarding the required level of assistance for this resident’s ADLs, particularly bed mobility and bedpan use. Several CNAs and nurses reported that, in practice, two staff were needed to safely reposition the resident and to place him on or off a bedpan, especially after he had gained weight, become more short of breath, and was no longer able to assist effectively. Some staff relied on word of mouth or personal judgment rather than written guidance, and contract staff reported there was no clear place to look up whether one or two staff were needed for ADLs. The Kardex posted in the resident’s room at the time did not specify the number of staff required for assistance with ADLs, and the Restorative Therapy to Nursing Communication form in effect at the time of the fall contained no instructions about staffing levels for ADL assistance. The facility’s Safe Resident Handling and care planning policies required that resident handling tasks be carried out in accordance with care plans and that care plans reflect MDS assessment results and current clinical functioning, but the resident’s care plan and supporting tools did not provide clear, consistent direction on the number of staff needed for repositioning and bedpan use prior to the fall.

The deficiency is further supported by staff statements that they interpreted or applied assistance levels differently. Some CNAs stated the resident had always been a two-assist for everything including repositioning and bedpan use, while others stated they sometimes used one staff depending on the day or the resident’s performance. Nursing staff who completed ADL assessments indicated the resident required two staff for bed mobility on night shift due to his size and limited grip, and that two staff were needed for placing him on a bedpan, but this was not clearly translated into the care plan or bedside communication tools. The DON acknowledged that the Kardex in the room at the time of the fall indicated a one-staff assist for bed mobility and toileting and that CNAs were expected to follow the Kardex, while also stating she was unsure of the precise meaning of MDS dependency levels. Overall, the lack of clear, consistent, resident-specific written directions regarding the number of staff required for repositioning and bedpan use, combined with reliance on variable staff judgment and verbal communication, led to the resident being assisted by a single CNA during bedpan use when multiple staff and nurses believed two staff were needed, culminating in the fall and fracture.