Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who had a history of morbid obesity, decreased mobility, and was care planned to require assistance from two staff members for bed mobility and transfers, experienced a fall resulting in a right hip fracture. The resident's care plan specifically indicated the need for two-person assistance due to self-care deficits and balance issues. Despite these documented needs, a nurse aide provided in-bed care with only one assist during a routine care activity. During the incident, the nurse aide rolled the resident onto his left side to perform hygiene care after a bowel movement. While the resident was being repositioned, he reached for an item on his nightstand and rolled out of bed, landing on his right hip. The resident reported pain, and subsequent assessment and x-ray revealed an intertrochanteric fracture of the right hip. The nurse aide later acknowledged that she did not follow the care plan and believed she could manage the task alone. Investigation confirmed that the nurse aide failed to adhere to the resident's care plan, which required two staff for bed mobility. This failure to follow the established care plan and provide adequate supervision directly resulted in the resident's fall and injury. The deficiency was cited as past non-compliance after review of clinical records, staff statements, and investigation documents.