Failure to Follow Care Plan and Safety Protocols Results in Resident Hip Fracture
Penalty
Summary
A deficiency occurred when a resident with diagnoses including hypertension, heart failure, and dementia, who required extensive assistance of two staff for bed mobility, was not provided with the necessary goods and services as outlined in their care plan. The care plan specifically required the use of fall mats on both sides of the bed to minimize the risk of injury related to falls. However, during an episode of care, a nurse aide provided care alone and without the fall mats in place, despite physician orders and care plan directives. While the nurse aide was changing the resident, the bed was elevated to over two and a half feet, and the aide turned away from the resident to retrieve a brief. During this moment, the resident rolled out of bed and landed on the floor, resulting in an angulated left hip fracture. Multiple staff interviews confirmed that standard procedure is to roll residents toward the caregiver to prevent falls, and that the care plan requiring two-person assistance and fall mats was not followed at the time of the incident. Documentation and witness statements further indicated that the nurse aide did not maintain appropriate supervision and failed to follow established protocols for resident safety. The Director of Nursing and Nursing Home Administrator confirmed that the lack of adherence to the care plan and failure to provide required safety interventions constituted neglect, resulting in actual harm to the resident.