Failure to Follow Two-Person Bed Mobility Care Plan Resulting in Fall and Fracture
Penalty
Summary
The deficiency involved the facility’s failure to implement a comprehensive, person-centered care plan requiring two staff to assist with bed mobility. The resident had an ADL self-care performance deficit care plan initiated on 7/14/25, which specified that bed mobility required assistance from two staff to turn and reposition in bed. A comprehensive MDS with an ARD of 1/29/26 documented that the resident was cognitively intact with a BIMS score of 15 and required substantial/maximal assistance for rolling left and right in bed. Despite these documented needs and the care plan intervention, a CNA provided in-bed care, including linen and brief changes, without the required second staff member. On 2/11/26 at approximately 10:05 PM, while CNA #1 was changing the resident’s bed linens and brief alone, the resident rolled to assist with care and rolled too far, exiting the bed and landing on the floor. CNA #1’s written statement indicated she was pulling the sheet from under the resident when the resident rolled and fell, and that the resident was not able to hold herself up even after grabbing the bed rail. The resident later reported that the CNA was alone while changing the bed linens when the fall occurred. An X-ray of the left shoulder taken the same day documented a proximal humeral fracture. The facility’s records, including interviews with the care plan nurse and DON, confirmed that the resident’s care plan required two staff for bed mobility and that the CNA did not follow this plan of care.
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