Failure to Follow Two-Staff Assist Orders Results in Resident Fall and Fracture
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, anxiety, and osteoarthritis was admitted with orders for comfort care, do not hospitalize, and required extensive assistance from two staff for bed mobility and activities of daily living (ADLs). The resident's care plan and physician orders specifically directed that two staff members assist with all ADLs and that a Hoyer lift be used for transfers, as the resident was non-ambulatory and at high risk for falls due to impaired mobility, incontinence, and cognitive impairment. On the day of the incident, a nurse aide (NA) provided incontinent care to the resident alone, despite the care plan and physician orders requiring two staff for such care. During the process of turning the resident onto their side, the resident became resistive and rolled away from the NA, ultimately falling from the bed to the floor. The NA was unable to prevent the fall, which resulted in the resident sustaining an acute distal femur fracture. The NA later stated she believed only one staff member was needed for ADL care and was unaware of the requirement to check the resident care cards prior to providing care. Interviews with facility staff confirmed that the resident required two staff for all care, including turning and positioning, and that this information was available on the electronic care card accessible to all staff. The NA involved did not consult the care card before providing care and proceeded alone, contrary to established orders and care plans. The incident led to the resident requiring a hospital transfer for a closed reduction of the fracture, after initial management in the facility.