Failure to Follow Transfer Protocols Results in Resident Fall and Hip Fracture
Penalty
Summary
The facility failed to provide an environment free from accident hazards for a resident at risk for falls, resulting in a fall with a hip fracture. The resident, who was cognitively intact but required substantial to maximum assistance for transfers and used a walker, had a care plan and physician's orders specifying that two staff members were required for all transfers. Despite these orders, a nurse aide assisted the resident alone during a transfer after a shower. During this process, the nurse aide slipped on water on the floor, causing both herself and the resident to fall. The resident sustained a hip fracture that required surgical intervention. Documentation revealed that the nurse aide was unaware of the updated transfer status requiring two-person assistance. The incident occurred when the resident was standing at the bars and the aide attempted to assist her alone, contrary to the care plan and physician's orders. The event was confirmed through staff interviews and review of clinical records, which indicated that the required level of supervision and adherence to fall prevention protocols were not maintained at the time of the incident.