Failure to Prevent Injury During Personal Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with right hemiplegia/hemiparesis, osteopenia, and a history of stroke, who was dependent on staff for bed mobility and personal care, sustained a significantly displaced acute proximal right humeral neck fracture with medial angulation during the provision of care by staff. The resident's care plan indicated a need for two-person assistance for all care, as well as specific interventions for impaired mobility and pain management. Despite these documented needs, the resident suffered a severe injury while being assisted by staff, with no staff able to identify a specific incident or fall that led to the fracture. Medical record review showed the resident had impaired cognition and was unable to move her right arm more than a few inches due to contracture. Staff interviews confirmed the resident's limited mobility and dependence on staff for all activities of daily living, including rolling and transferring. The injury was discovered when redness and swelling were noted on the resident's right upper extremity, and subsequent imaging confirmed the fracture. Staff were unaware of any event that could have caused the injury, and the DON acknowledged the fracture must have occurred during care, given the resident's inability to move her arm independently. The resident experienced increased pain following the incident and required orthopedic surgical follow-up. The injury was further complicated by the resident's underlying conditions, including osteopenia, which made her bones more susceptible to fracture. The coroner's findings indicated that the fracture contributed to the resident's decline and eventual death, with the injury likely occurring during staff-provided care. This deficiency affected one resident out of three reviewed for accident hazards in a facility with a census of 75.