Resident A. Resident A was a 67-year-old African American man diagnosed with vascular dementia (without behavioral disturbance), Alzheimer’s disease, and nonspecific other cognitive symptoms and of altered awareness. Resident A’s BIMS score of 5 indicated severe cognitive impairment. In addition, he was diagnosed with hypertension, an unspecified mood disorder, a contracture of the left hand, and dysphagia. His total Braden Scale score was 14, with subscale scores of 3 (Sensory), 2 (Moisture), 2 (Activity), 2 (Mobility), 3 (Nutrition), and 2 (Friction/Shear). A score of 2 in the activity subscale is chairfast, ie, the resident cannot bear his own weight and must be assisted into a chair or wheelchair.
In the first repositioning event, Resident A turned to his right side from the back-lying recumbent position with considerable difficulty. Prior to the repositioning event, the nursing assistant tried to straighten his legs, which were flexed at the knee; however, straightening his legs resulted in Resident A immediately reverting back to bent knees and even more hip and knee contraction. The nursing assistant finally stood on the right side of the bed (from the head-of-bed position, the patient’s right side) and used her body weight in a heaving/lurching motion to turn Resident A to his right side; his entire body moved rigidly as 1 unit, with contracted arms and legs.
The second repositioning event involved the same nursing assistant moving Resident A to his left side from a recumbent position on his back. Resident A moved more flexibly when turned to the left, and his arms and legs contracted only minimally. During this second repositioning event, the nursing assistant was able to reposition Resident A in one fluid motion by using her arms only.
In both repositioning events, Resident A demonstrated what appeared to be repetitive and non-purposeful movements, ie, he rubbed his heels against the sheets in an up-and-down motion (dorsiflexion and plantar flexion) throughout the repositioning event and also moved his shoulders up and down rhythmically, causing his elbows to tap on the sheets. On his right side, Resident A continued the repetitive heel and shoulder motions even after the repositioning event was complete. On his left side, the repetitive motions stopped as soon as the repositioning event was completed.
Resident A presented with a total of 28 days of monitored time (Table 2). Resident A was chairfast according to the Braden Scale activity subscale and spent the vast majority of his time (95%) tilted in bed or a chair <50 degrees, with only 4% upright time sitting in bed or a chair. The sensor data also exposed a distinct side preference, with only 10% of Resident A’s time spent on his right side.
Resident B. Resident B was a 56-year-old African American woman. Although Resident B did not have a recorded diagnosis of dementia, her BIMS score was 6, indicating severe cognitive impairment. Her total Braden Scale score was 13, with subscale scores of 3 (Sensory), 2 (Moisture), 2 (Activity), 1 (Mobility), 3 (Nutrition), and 2 (Friction/Shear). Therefore, Resident B was also considered to be chairfast.
Two (2) repositioning events were observed 15 days apart. In both events, Resident B moved from the left-side position to the right-side position. Resident B’s bed was positioned with the left side of the bed (as viewed from the head of the bed) flush against the wall, with both side rails up. When asked about the rationale for bed positioning against the wall, the nursing assistant indicated that Resident B was both afraid of falling and considered a fall risk; the wall served as both a comfort and safety measure. Furthermore, a thick, heavy safety mat for fall injury prevention was placed on the floor and ran the length of the bed, which stabilized bed wheel movement during repositioning events. Given the limited nursing access to the resident for repositioning, the nursing assistant stood at the head of the bed, stooped over the resident’s head, reached for the turning sheet, and using a fluid pulling and twisting motion to create angular momentum, subsequently repositioned the resident onto another side.
In the first repositioning event, the nursing assistant approached Resident B and spoke encouragingly. Resident B appeared anxious; her tone of voice was fearful, yet loud, and her speech was unintelligible with a worried facial expression. In a soothing tone, the nursing assistant explained her plan was to help reposition the resident and make her more comfortable. Resident B’s facial expression relaxed, and she appeared consoled by the nursing assistant’s explanation. During repositioning Resident B tensed up, with her limbs drawing toward her body, and then relaxed after the repositioning event was complete.
During the second repositioning event, Resident B’s muscles tensed up with her limbs drawing closer to her body. Resident B grabbed the left handrail and appeared unable to let go; the nursing assistant gently unwound Resident B’s fingers in order to turn her. Grabbing the handrail did not appear purposeful. Instead, it appeared when Resident B’s fingers made contact with the rail at the beginning of the repositioning event; her arm was moving through the air, and she involuntarily grasped tightly. Resident B’s repositioning demonstrated subtle repetitive, non-purposeful movements. She moved her heels about 1 cm up and down (dorsiflexion and plantar flexion) throughout the repositioning event—a barely perceptible movement most visible after the repositioning was complete, when the sheet was replaced.
Resident B had a total of 24 days of monitored time (Table 2). Resident B, also chairfast according to the Braden Scale activity subscale, spent 96% of her time reclining in bed or a chair (vs. 4% upright time) (Table 2). While reclining in bed or a chair, she was positioned on her back the majority of the time (44%), with similar amounts of time spent on each side (27% right recumbent vs. 25% left recumbent).