Failure to Provide Ordered Hipsters for Residents at Risk for Falls
Penalty
Summary
The facility failed to provide ordered hipster garments for three residents with fall histories, despite physician orders and care plans directing that they be encouraged to wear hipsters and that refusals be documented. Resident 1 had depressive and adjustment disorders, a history of falls, and a BIMS score of 11 indicating moderate cognitive impairment. Physician orders effective November 3, 2025, and re-entered January 5, 2026, required staff to encourage hipster use every shift and document refusals, and the resident’s care plan reflected this fall-risk intervention. On January 5, 2026, at approximately 11:00 AM, Resident 1 was observed in the lounge/dining area without hipsters. Resident 2 had dementia, atrial fibrillation, a history of falls, and a BIMS score of 99 indicating inability to complete the cognitive interview. An order effective December 5, 2025, and a care plan effective August 13, 2025, directed that Resident 2 be encouraged to wear hipsters every shift with refusals documented, yet this resident was also observed at the same time without hipsters. Resident 3 had dementia, depressive disorder, a history of falls, and a BIMS score of 2 indicating severe cognitive impairment. Physician orders effective February 17, 2025, and a second order written January 5, 2026, required that Resident 3 be encouraged to wear hipsters at all times, and the care plan mirrored this intervention. On January 5, 2026, at approximately 11:00 AM, Resident 3 was observed in the lounge/dining area without hipsters. A nursing assistant reported that residents did not have any hipsters in their rooms and stated that none of the residents refused hipsters; she also noted that Resident 3 was already up and groomed when she arrived. A laundry employee stated there were no hipsters available for these residents, though there might be some in a washer. Central supply staff later confirmed that multiple pairs of new hipsters in all sizes were locked in a cabinet in her office. The DON confirmed that no hipsters were present in the rooms of the three residents and stated that each resident should have two pairs, demonstrating that ordered and care-planned hipster use was not implemented for these residents.
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