Failure to Follow Two-Person Assist Requirement During Bed Mobility Results in Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident free from accident hazards and to provide adequate supervision during bed mobility, resulting in a fall from bed and injury. On the evening in question, CNA #1 performed an in-bed linen and brief change for Resident #1 without the required two-person assistance. During this care, the CNA rolled the resident to her side to remove soiled linens; as the CNA pulled the sheet from under the resident, the resident rolled too far and fell from the bed to the floor. The CNA reported attempting to reach over and keep the resident from falling, and the resident attempted to hold herself up by grabbing the bed rail, but she was unable to maintain her position and continued to fall. Resident #1 had been admitted with diagnoses including hypertension, and later had an additional diagnosis of a displaced fracture of the upper end of the left humerus, subsequent encounter for fracture with routine healing. The most recent MDS assessment showed the resident was cognitively intact with a BIMS score of 15 and required substantial/maximal assistance for rolling left and right in bed. The Kardex in effect at the time specified that the resident required two staff for turning and repositioning in bed. Despite this documented need, CNA #1 provided the linen and brief change alone and stated she was unsure how many staff were required for bed mobility at that time, even though CNAs had access to the Kardex system and were expected to review it daily. Following the fall, an X-ray of the resident’s left shoulder documented a proximal humeral fracture, consistent with the reported history of a shoulder injury from a fall out of bed. Resident #1 later described that during the linen change she was rolled onto her side, began to fall when the bed pad was removed, tried to stop herself, and that the CNA also tried to catch her but she still landed on her left side on the floor. She reported that the CNA then left the room to obtain assistance, after which nursing staff came to assess her and she was transported to the hospital. The DON confirmed in interview that the fall occurred during a linen change when the CNA did not follow the Kardex requirement for two staff during bed mobility.
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