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F0600
G

Failure to Follow Care Plan for ADL Assistance Results in Resident Fall and Fracture

Greensburg, Pennsylvania Survey Completed on 04-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to follow a resident's care plan for assistance with activities of daily living (ADLs) and fall prevention. The resident, who had a diagnosis of morbid obesity and was identified as being at risk for falls due to balance issues, required assistance from two staff members for bed mobility and transfers, as documented in the care plan. Despite this, a nurse aide provided in-bed care with only one staff member present. During the provision of care, the resident was rolled onto his left side to be changed after a bowel movement. While the nurse aide was cleaning the resident, he reached for an item on his nightstand and rolled out of bed, falling onto the floor and landing on his right hip. The resident reported hip pain, and subsequent assessment and x-ray revealed an intertrochanteric fracture of the right hip. The incident was confirmed by statements from both the nurse aide and the resident, as well as documentation in the clinical record. The facility's investigation determined that neglect had occurred because the nurse aide did not adhere to the care plan, which required two staff for bed mobility. The nurse aide had previously completed training on preventing, recognizing, and reporting abuse, but failed to follow the established protocol for this resident, resulting in the fall and injury.

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