Failure to Follow Transfer Protocols Results in Resident Fall and Hip Fracture
Penalty
Summary
The facility failed to ensure that a resident was protected from neglect, resulting in a fall with a fractured hip. The resident, who was cognitively intact and required substantial to maximum assistance for transfers due to chronic obstructive pulmonary disease and other diagnoses, had a care plan and physician's orders specifying that two staff members were required for all transfers using a wheeled walker. Despite these orders and care plan interventions, a nurse aide assisted the resident alone during a transfer after showering, without a second staff member present. During this process, the nurse aide slipped on water on the floor, causing both herself and the resident to fall. The resident sustained a visibly shortened and externally rotated right leg, and was subsequently diagnosed with a hip fracture requiring surgery. Documentation revealed that the nurse aide was unaware of the change in the resident's transfer status to a two-person assist, despite having received prior education on abuse and neglect. The nurse aide's failure to follow the care plan and physician's orders directly led to the resident's fall and injury. The incident was confirmed through review of clinical records, staff interviews, and investigative documents.