Failure to Ensure Use of Ordered Hip Protectors for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including Alzheimer's dementia, right femur fracture, osteoporosis, and severe cognitive impairment, was not provided with required hip protectors as ordered by the physician and outlined in the resident's care plan. The care plan specified the use of padded hip protectors at all times to prevent hip fractures due to the resident's high risk for falls. Despite this, observations on three separate occasions revealed that the resident was not wearing the hip protectors. Interviews with staff confirmed that the resident was supposed to have hip protectors in place for safety, and that nursing staff were responsible for ensuring their use. The DON acknowledged that the charge nurse was responsible for ensuring the devices were utilized and that she was ultimately accountable for compliance with physician orders. The facility's fall prevention policy also required maintaining an environment as free from accident hazards as possible and implementing appropriate interventions to minimize complications from falls.