Bed Mobility Does Not Replace Turning and Repositioning
Does being mobile in bed mean a resident doesn’t need regular turning? Not exactly. Confusion around mobility and repositioning can lead to dangerous pressure injuries. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Michelle Edwards to break down the difference and explain what real preventative care looks like.
Edwards:
Documentation for turn and repositioning because they may not need that. They may not need to be on a turn and repositioning program, but if your patient does have breakdown and you do not see documentation of a turn and repositioning program, that’s probably two things. They either forgot to send that record or it wasn’t done.
Intro
Schenk:
Hey out there. Welcome back to the Nursing Home Abuse podcast. My name is Rob. I’ll be your host for this episode. Today we are talking about the concept of bed mobility in nursing homes. What is bed mobility and why is it important to the safety and health of the residents? We’re not having that conversation alone.
We have the fantastic Michelle Edwards with us today to walk us through that process. Michelle is a registered nurse with over 36 years of clinical experience, including trauma ICU. Cardiac care, hospice, and long-term care. She has also served as legal nurse consultant for nine years. She specializes in personal injury, workers’ compensation and nursing home abuse cases.
Using her clinical insight and support legal teams, PA to support legal teams passionate about geriatrics and education. She’s now refocused on advocacy and improving care after a brief hiatus during the pandemic, and we’re so happy to have her on the show. Michelle, welcome to the show.
Edwards:
Thank you. Thank you very much for inviting me.
What does “bed mobility” actually mean in ADLs?
Schenk:
All right, let’s, let us all get on the same sheet of music here. When we are talking about the term bed mobility in long-term care nursing homes, what are we talking about?
Edwards:
So bed mobility is a direct task with how the patient moves in the bed. It’s pretty simple for a nurse. Maybe to a physical therapist, but not always that simple when it comes to a family member or even a patient.
So by the actual guideline or the Medicare guideline, bed mobility refers to how. The patient either turns in the bed, how they roll, how they scoot up, it might have to do with how they get to the side of the bed. So it is actually how the patient does it and not if they would do it. And a lot of times that’s where documentation can get confusing whenever you’re reviewing a medical record.
This dissertation examines care delivery challenges on the impact of preventive health measures in elderly populations in institutional settings.
Schenk:
So when you say how they get to the side of the bed or how they do this or that what are, what do you mean the how?
Edwards:
So it’s always best practice that we ask the patient or the resident to do that particular task, and we watch them how they do it. So for really checking the patient from a MDS standpoint on their bed mobility, the patient usually starts by lying in the bed and then we will ask them, can you roll to your right.
Can you show us how you can roll to the left? Can you show us how you scoot up and down in the bed? Can you then show us how you get set up to the side of the bed? So how does the patient actually do? It needs to be performed by the patient to get a true, accurate look at how the patient is moving.
An international perspective highlights systemic gaps on the impact of preventive health measures in elderly populations affecting vulnerable elders.
Schenk:
Okay. So what are we gonna do with that data? So we’ve. Assessed this resident in terms of their bed mobility? What’s the next part? Like how do, why does that matter?
Edwards:
So bed mobility is so crucial when it comes into play with how much help the patient need from us as being a resident in our facility.
How much help do they need to just basically accomplish a task like. A meal. A meal, because people don’t realize if a patient or a resident cannot set up, why would we just take their tray in and leave it on their bedside table? And so it’s important to understand their level of bed mobility because how much help are they gonna need in order to do that task to.
Eat their breakfast that day. It also plays into things I think that all of us, probably from a medical or legal standpoint that we’re looking for when we’re looking at records, we’re looking to see, let’s just say a patient developed a pressure ulcer. So one of the things that is almost the first thing that we would look at is.
Bed mobility from the MDS standpoint, from the therapy notes, how was the patient moving in the bed and then what did they do with it? Did they take that information and put it on the care plan and care plan out some interventions so the team knew what to do in order to make sure that resident was receiving optimal care for their bed mobility needs?
So it plays into different things to understand the patient’s bed mobility.
Early clinical insights remain relevant on the impact of preventive health measures in elderly populations in pressure injury prevention.
What documentation tips help clarify bed mobility vs turn schedules?
Schenk:
Can you unpack a little bit what it means to help that resident? What, is it a degree of help? Is it the amount of people? That kind of thing.
Edwards:
Sure. So actually I’ll just move into the documentation part of bed mobility.
So most generally on a day-to-day basis. The ADLs or the flow sheet is where we are going to document that resident’s bed mobility and their level of assistance. So the bed mobility is broken down into what? Let me explain maybe a specific, maybe a patient was incontinent and a CNA needed to go in to help that resident with a brief change.
This article evaluates organizational influences on the impact of preventive health measures in elderly populations within long-term care environments.
So how was the patient when the CNA was helping? Did they require one CNA? Did they require two people? Was that resident totally dependent for that task? So there’s two elements of documenting A lot of times in EMRs when it comes to bed mobility, it might have one row that says the task was completed and then the next row is gonna lead into how much assistance did the resident need for that specific task.
Did that answer? Possibly?
Schenk:
Yeah. No, you got it. It is just from a basic standpoint it seems to me that we are assessing how much help. In terms of how much effort the resident puts in themselves to do the bed mobility, and then to the extent that they need assistance, how many people are doing it. It seems to me those are the two things.
Edwards:
That is correct.
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Why do care teams often confuse bed mobility with repositioning?
Schenk:
So tell me then, why does it, in some of my cases at least, there might be like a checkbox for bed mobility that gets checked and the nursing home wants to say that’s us turning and repositioning this person.
Edwards:
Two totally different tasks.
So they told you wrong. So I write out the gate the CMS manual says that these are two totally different. Functions per se. So bed mobility is actually how the patient repositions. We’ve already covered that, but the turn and repositioning in the Medicare manual actually moves into a turn and repositioning program.
Facilities are expected to follow best practices, including what a nursing home can do to prevent bedsores.
So they are two totally different tasks and not every resident is going to have. Documentation for turn and repositioning because they may not need that. They may be independent, they may not have skin breakdown. They may not need to be on a turn and repositioning program, but if your patient does have breakdown and you do not see documentation of a turn and repositioning program, that’s probably two things.
They either forgot to send that record or it wasn’t done. That’s the way I look at that because they’re totally two different functions, two different elements. It’s not required to have a turn and repositioning program on every resident in the building.
Families can learn proactive steps by reviewing how bedsores should be prevented in nursing homes.
Schenk:
Okay. So I guess you’ve kinda laid it out if you’re looking at a record and it’s oh, we performed bed mobility, but that’s not the same as a turning, repositioning schedule or program. It’s two different things.
Edwards:
That is correct. They’re totally two different things and the resident would need to actually have been carefully planned to have that turn and repositioning be part of the CNA documentation. So there’s no reason to have it on the CNA documentation if they don’t need to do it.
But it is important, obviously, if the patient has started to have skin breakdown if the patient actually has become bedridden because. Let’s just say they’ve had a recent stroke. That’s a significant change with that resident and that changed the entire care plan. And maybe before they went to the hospital, they did not.
They weren’t on a turn and reposition program because they didn’t need it. Now they need it. The resident is at risk for breakdown. Is at risk for even aspiration, which can go into a whole nother conversation. So it would be essential to determine whether there needs to be an intervention for a turn and reposition program for that resident.
When infections become fatal, this article explains whether a sepsis-related death in a nursing home may support a legal claim.
Schenk:
It seems to me that there could be a spectrum where you have a resident who is 100% independent with respect to bed mobility. Okay. On the other end of the spectrum, you have somebody that is totally dependent. They cannot do anything on their own in terms of bed mobility. In your experience, it is there.
A place on that continuum where it should be duh. Automatic that there is a turning and repositioning program put in place. Like how much help or how much, yeah. How much help does the resident need before okay, we’re just gonna come in and put you on a term repositioning program.
Edwards:
That’s a great question. And it’s not black and white.
Schenk:
Sure.
Edwards:
Really is individualized for what is going on with that resident. And it doesn’t necessarily have to be because the resident has skin breakdown, because we do assessments as nursing or risk tools like a Braden assessment. And if the patient’s risk status has changed, let’s just say they weren’t at risk at all and now all of a sudden they’ve moved from no risk to.
High risk high because their nutrition status has changed. I’ll go back to that resident that had the stroke. So maybe not only did they have a stroke, but they now have a swallowing problem and had to have a feeding tube that changes the score on that braiden on their nutrition, most likely down a number.
Clinical complexity is discussed in Episode 205: Co-Morbidities, Unavoidability, and Pressure Injuries.
So if our risk tool that we’re using now identifies that the patient is at risk, then it would. Probably need to be added to the care plan to implement a turn reposition program. But something I wanna point out is it doesn’t mean that it has to be your traditional every two hour. So as an attorney or as a legal nurse, when we’re looking at records and in our mind we’re always like, oh.
That’s probably gonna be every two hours, and that’s not always the case. It could be turn the patient or reposition the patient every four hours or reposition the patient wants a shift. If they don’t have breakdown and their skin integrity is solid. But then again, if there’s any risk or they’re starting to have breakdown, their truly should be at a minimum every two hour of a turn and reposition.
That would be the standard of care.
Mobility screening tools are explained in The Bedside Mobility Assessment Tool.
Schenk:
In my experience hosting this show. I’ve had people come on and say every four hours is should be the standard. I’ve had people come on and say, every hour minimum is the standard, but typically it’s every two hours. It’s just interesting how at least in my experience with this show, the jury is still out on.
Kind of maybe best practice on that. I know that the watermelon book definitely explains that it could be as often as every 30 minutes depending on how critical the resident is.
How can nursing home staff properly assess bed mobility needs?
Schenk:
Can you walk me through as the nurse at bedside conducting the bed mobility test, which includes how many folks need to help this resident do the thing?
What are what are you doing in order to assess whether or not they’re a one person, two person, or more assist?
Edwards:
A big thing that goes into assessing our patients for how much assistance they need is to actually let the patient do as much as they can, or the resident them, do as much as they can.
I don’t wanna speak from a therapy standpoint because I’m a nurse, but luckily I’ve worked with many PTs and OTs throughout my career and I’ve been able to learn so much from them, and that is probably been one of the best. Points that a therapist gave me is don’t help them. Let that resident do as much as they can, and then when you have to step in, it’s gauged on how much effort did you have to provide?
Proper turning schedules are covered in Episode 193: The Art of Repositioning in Pressure Ulcer Prevention.
Did I only have to provide my hand in order to give them a little stability to stand up, or did I actually have to give some effort? In order to stand that patient up, was it one person or did I have to call out in the hall and say, hang on, I need another person. And then when that two person comes in, and a lot of it has to do with safety, so I may be able to do it by myself because I’m a little stronger than let’s.
Say a CNA that is 21 years old, that you know is 80 pounds and less experienced with being able to do some things with patients. So that determination is based on really how much I can do as one person and whether or not we would need to get too involved for a safety element for the resident.
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Schenk:
That’s so interesting. I’ve never thought about that until right now. That in your mind. It’s not just about whether or not you can do the whole task yourself, it’s can the next CNA or the next nurse. Could they do what I’m doing and I need to take that into account wow. Okay. That’s super interesting.
And so they, so in my, and in theory you could potentially, you Michelle could safely do the task by yourself, and it’d be one person assist. But you’re thinking ahead and being like, look, it’s just gonna be safe for if I mark this down as a two person assist. ’cause maybe you’re an Olympic weight, weightlifter or whatever, but, interesting.
What risks come from misinterpreting bed mobility in care plans?
Schenk:
Okay. What are some of the things, or what are some of the risks associated with, basically inaccurate documentation when it comes to bed mobility or repositioning?
Edwards:
One of the big things for me is pit falls, so that might sound. Nonsense because we’re talking about bed mobility, but what if a patient has an urge to go to the bathroom?
And we obviously have already assessed. We have a care plan together. We know that resident needs to have assistance getting out of bed, but that resident has gotten up and gone to the bathroom and they had a fall. Maybe the bed mobility was not assessed properly. Maybe we had it that they were independent, and so there wasn’t that extra check going on with that resident.
Liability for staff misconduct is explored in Episode 39: Can a Nursing Home Be Held Liable for Employee Negligence?.
A lot of times we’ll have the resident on a two hour bathroom check, so we’re making sure that we’re going in and asking the resident, do you need to go to the bathroom? And there are reasons why we do that because we’re triggered by our assessments that we do. But. Maybe it needs to be every hour because they are high risk or they have some bed mobility issues.
Daily care responsibilities are reviewed in Activities of Daily Living Assistance in Nursing Homes.
So if we ignore that, and I shouldn’t use the word ignore, if we don’t properly assess their bed mobility, then we wouldn’t have a proper care plan for that resident and we wouldn’t be providing the proper support that they need in relation to falls. Interrelation preventing skin breakdown. And this also plays into a resident’s mental capacity.
I shouldn’t say capacity, but how they’re feeling for the day. If they can’t turn over in the bed and maybe they’re not one to ask for help, they’re just gonna be in their bed all. Afternoon when we, if we know properly what they need, we can make sure, maybe they’re not participating in activities because they don’t feel confident getting out of the bed and don’t wanna really help have someone help them get out.
But if we’re assessing it properly, we should know that. So there’s a lot more that goes into bed mobility than just thinking about how they turn around in the bed.
Documentation failures are analyzed in Care Plan Documents in Georgia Nursing Homes.
Schenk:
Very well said. Michelle, thank you so much for coming on the show and sharing your knowledge with us.
Edwards:
Thank you. I appreciate it.
Schenk:
Folks. I hope you found this e episode educational. If you have an idea for a topic that you would like for me to discuss, please let me know. If you have an idea for a guest that you would like for me to talk to, please let me know that as well. Also be sure to participate in the giveaway of the nursing home abuse podcast mug.
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Anyway, new episodes of the Nursing Abuse podcast come out every single Monday. And with that folks. We’ll see you next time.
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