Failure to Provide Required Supervision During Ambulation Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and safe ambulation assistance to a resident with dementia, lack of coordination, abnormal posture, generalized weakness, and moderately impaired cognition (BIMS score of 7). The resident’s MDS and care plan identified dependence on staff for transfers and ambulation with a rolling walker, and a fall risk assessment classified the resident as high risk for falls. The care plan and physician’s orders specified assistance of one staff member for transfers and ambulation with a rolling walker for distances of 45–75 feet with rest breaks as needed. Facility policy for ambulation with a walker required staff assistance as indicated by MD orders and directed staff on how to support a resident if a fall began. The DON stated that a gait belt should have been used during ambulation and that any refusal should have been documented, although there was no specific provider order for a gait belt. On the evening of the incident, a nursing assistant assigned to the resident reported assisting the resident from the dining room toward the resident’s room. During this ambulation, the NA left the resident standing in the hallway, instructed the resident to remain there, and went to assist another resident who was out of her line of sight. The NA confirmed she did not have or apply a gait belt and did not remain with or hold onto the resident during ambulation, despite knowing the resident required assistance of one and a gait belt. While the NA was away, the resident began walking toward his/her roommate and another staff member, then turned to look at another person, lost balance, and fell onto the right side. The resident initially complained of back discomfort that subsided, later reported right upper leg discomfort, and was subsequently found at the hospital to have sustained a closed right femoral neck fracture requiring ORIF surgery. The DON confirmed that the NA should not have left the resident standing alone and that the NA failed to follow the facility’s ambulation policy.
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