Failure to Follow Two-Person Assist Care Plan During Bed Mobility Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented an established, individualized care plan requiring two-person assistance for bed mobility for one resident. The resident had been admitted with severe morbid obesity, an above-knee amputation of the left leg, cerebrovascular disease, and unspecified dementia. A quarterly MDS assessment showed the resident had a BIMS score of 8, indicating mild cognitive impairment, required substantial to maximum assistance for bed mobility, and was dependent for toileting hygiene. The resident’s care plan, initiated more than four years earlier, specified that the resident required participation of two or more staff for repositioning and turning in bed due to an ADL self-care performance deficit and impaired mobility. On the day of the incident, the resident was in bed when a CNA (S4CNA) provided peri-care and bed mobility without a second staff member present, contrary to the resident’s care plan. During this care, the CNA turned the resident to the left side in bed to change the resident’s brief. The resident grabbed onto the mobility rail to assist with turning and continued to roll completely out of the bed, falling to the floor on the left side of the bed. The nurse (S3LPN) heard the resident yell out and, upon entering the room, observed the resident lying on her left side on the floor with only the single CNA present. Following the fall, staff observed that the resident’s right leg was hyperextended on the floor, with instant bruising noted to the right ankle and top of the foot, as well as skin tears to the left abdomen and right center chest area. The right leg/ankle was in an unnatural position, and visible bruising was present on the right lower leg. The resident was lifted from the floor using a mechanical lift and returned to bed, and EMS was called for transport for post-fall evaluation. Hospital records later documented that the resident sustained an acute mildly displaced and angulated comminuted periprosthetic fracture of the proximal tibia extending to the distal tip of the tibial prosthesis, an acute mildly displaced fracture of the proximal fibula, and a hematoma of the proximal medial lower leg. In interviews, the CNA acknowledged providing care without a second staff member, not reviewing the Kardex prior to care, and not being aware or not having recently reviewed the resident’s care plan requirements for two-person assistance.
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