F0689

D

Failure to Update and Follow Two-Person Assist Requirement for Bed Mobility Leading to Fall

Bronx, New York Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and appropriate assistance during bed mobility for a resident, resulting in a fall from bed and head injury. The resident had diagnoses including hemiplegia, aphasia, and diabetes mellitus, and the Quarterly MDS documented moderate cognitive impairment, impaired upper and lower extremities, dependence on staff for toileting and dressing, substantial assistance for rolling left and right, and frequent bowel and bladder incontinence. Despite this, the Visual/Bedside Kardex reports on multiple dates, including the day of the incident, listed the resident as requiring substantial assist of one staff for rolling left and right.

On the date of the incident, a CNA provided one-person assistance while attempting to turn the resident onto the right side during care. According to the nursing progress note, the CNA reported that the resident tried to hold onto the metal part of the bed with the left side, reached out too far, and rolled off the bed headfirst onto the floor. The resident was found face down on the floor with a left parietal hematoma with laceration and right upper face skin excoriation, and the CNA was at the bedside. Interviews with the resident’s sibling and the complainant indicated that the resident had a history of multiple strokes, paralysis from the waist down, limited mobility in the left arm and leg, and that concerns had previously been raised with the facility that the resident required two-person assistance for care, but the resident continued to receive one-person assistance at the time of the fall.

Therapy documentation prior to the incident showed that the resident’s bed mobility needs had been assessed as requiring more than one staff member. Physical therapy progress reports and recertification documents dated from late July through early September recorded that the resident was totally dependent for rolling left and right in bed, with attempts to initiate movement, and specifically commented that the resident was able to initiate rolling but required at least two persons to complete rolling. These notes also recommended continued verbal cues for task sequencing to reduce the risk of falls and injury. Occupational Therapist #1 confirmed that as of early September, rolling left and right required two-person assistance for safety and that this should have been carried over because it posed a safety and fall risk.

Interviews with the DON, Director of Rehabilitation, and Assistant DON revealed that the mechanism for communicating therapy recommendations to nursing at the time relied on hard copy documents passed from therapists to nurse managers, who would then update resident tasks. The DON stated that the incident had been investigated and that the resident was noted as one-person assist for bed mobility, and therefore they believed there was no care plan violation at that time. However, when the surveyor reviewed the PT progress note from early September documenting the need for two-person assistance for rolling, the DON could not explain why this recommendation was not followed and could not locate documentation of any updated communication after a prior May recommendation to change from two-person to one-person assistance. The Director of Rehabilitation stated that the PT note indicating the need for two-person assistance for rolling was current as of early September and that the task list should have been updated to two-person assistance, but there was no documented evidence that this occurred or that nursing was made aware. The Assistant DON confirmed that resident task lists can and should be updated during therapy if a decline is noted and that nursing should be notified so tasks can be adjusted accordingly.