Neglect Resulting in Resident Fall and Femur Fracture
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of falls, and muscle weakness was left unattended in an elevated bed by a nurse aide. The resident required total staff assistance for activities of daily living, including bed mobility and transfers, and the care plan specified that two staff members were needed for these tasks, with the bed to be kept in the lowest position for safety. Despite these requirements, the nurse aide left the resident alone while the bed was raised to retrieve a washcloth from the bathroom, resulting in the resident falling from the bed. Following the fall, the resident was found on the floor on her left side, holding onto the enabler bar, with her legs bent underneath her. Initial assessments by nursing staff did not reveal any visible injuries or signs of pain, and neurological checks were within normal limits. The resident was assisted back into bed using a Hoyer lift, and care was provided by two staff members as per protocol. The nurse aide involved was educated on the importance of following the care plan and not leaving residents unattended in elevated beds. Subsequent follow-up revealed swelling of the resident's right knee, and an x-ray confirmed a displaced and overlapping comminuted distal fracture of the right femur. The incident was investigated and substantiated as neglect, as the nurse aide failed to follow the resident's plan of care, directly resulting in the fall and serious injury.