Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow the resident’s care plan requiring two-person assistance for bed mobility, which resulted in a fall and subsequent right femur fracture. The resident was admitted with cervical fracture and muscle wasting/atrophy and had a BIMS score of 3/15, indicating impaired cognition. The most recent MDS documented the resident as dependent for bed mobility, and the ADL care plan dated 11/14/2025 specified a two-person assist for bed mobility. The Director of Rehabilitation confirmed that this resident required two staff during care for safety and remained a two-person assist for bed mobility. On 12/31/2025, during perineal care, a CNA provided care alone and repositioned the resident toward themselves. During this care, the resident, described by the LPN as very antsy, moved and rolled out of bed. An incident report documented that the resident complained of right leg pain, could not move the right lower leg, and was assisted back to bed by two staff, with vital signs taken and a STAT X-ray ordered. A subsequent physician readmission note dated 1/15/2026 documented that the resident was sent back to the hospital for possible trauma and was found to have a right femur fracture requiring surgery in the OR. The DON stated that the expectation is that when a resident is care planned as a two-person assist, there should be two people in the room, indicating that this expectation was not met at the time of the fall.
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