F0600

J

Neglect Due to Failure to Follow Two-Person ADL Assistance Care Plan Resulting in Hip Fracture

Port Orange, Florida Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from neglect by not implementing care plan interventions requiring two-person assistance with activities of daily living (ADLs). The resident had an active care plan, revised on 10/16/25, that identified an ADL self-care performance deficit related to atrial fibrillation, hypertension, overactive bladder, history of breast cancer, dementia, anemia, and an end-stage disease process. The care plan specified that the resident required substantial/maximal assistance of two staff for bed mobility and was dependent/total with transfers, requiring a mechanical lift, two-person assistance, and a medium pad. The care plan also documented that the resident was at risk for falls or fall-related injury due to impaired mobility and decreased safety awareness, with interventions including a bariatric mattress, bed in lowest position, bolsters to bed, a left-side mobility bar, and cues for safety awareness.

Despite these documented needs, the resident’s CNA task list from 12/10/25 through 01/10/26 showed that the resident received one-person ADL assistance on 21 of 31 reviewed days. On 01/10/26, the resident’s ADL care was again provided by only one CNA instead of two, contrary to the care plan. CNA B reported that this was her first day of work and that she was being coached by CNA A. When they entered the room around 5:15 AM, CNA A directed CNA B to care for the other resident in the room while CNA A cared for this resident. CNA B pulled the privacy curtain and began care on the other resident. She then heard a thud and CNA A exclaiming that the resident was on the floor. When CNA B looked, she saw the resident on her back, toward her right side, with her head toward the top of the bed, which was in a high position, and the resident was complaining of right hip pain.

The DON later learned that the resident had fallen from the bed while CNA A was providing care alone. CNA A admitted she had not reviewed the care plan or Kardex before providing care and confirmed she provided care by herself. During a reenactment, CNA A demonstrated that the resident had been positioned on her right side, holding the mobility bar, with the bed at about waist height. CNA A walked to the doorway to ask the nurse to perform a dressing change because the resident’s dressing was soiled, leaving the resident in that side-lying position with the bed elevated. As CNA A was returning from the doorway, the resident’s left leg bent and its weight pulled the resident over the side of the bed to the floor, where she landed on her back and rolled to her left side. The resident complained of hitting her head, and CNA A called for help. Subsequent clinical documentation, including an SBAR note and radiology and emergency department reports, confirmed that the resident sustained a mildly displaced right femoral neck fracture with femoral shaft impaction, described as an acute sub-capital fracture of the right femoral neck, after being dropped or falling during transfer/bed mobility care provided by one CNA instead of the two-person assistance required by the care plan.

Removal Plan

• Suspended the CNA involved with the incident and terminated the CNA.
• Reported the CNA to the board of nursing.
• Held an ad hoc QAPI committee meeting with the Administrator, DON, and Medical Director to review the incident and implement a plan.
• Completed neglect education for licensed nurses and CNAs on proper positioning during routine care, wound care, and repositioning in bed, with emphasis on abuse and neglect, and obtained staff signatures prior to the staff's first shift.
• Completed assessments of residents to determine ADL assistance needs while in bed, proper positioning during care, and the number of persons required to assist during in-bed care.
• Completed competencies for licensed nurses and CNAs in providing ADL care and repositioning during in-bed ADL care.
• Conducted an ad hoc QAPI meeting to complete root cause analysis and discussion.
• Completed the root cause analysis identifying the root cause as the CNA's failure to follow the resident's plan of care.
• Conducted an ad hoc QAPI meeting to ensure all QAA/QAPI components were addressed and the facility was in substantial compliance.
• Initiated ongoing monitoring by the Administrator, NHA, DON, Unit Managers, IPCO, SDC, shift supervisor, and weekend supervisor to ensure CNA documentation matched the Kardex, the appropriate number of staff were observed providing care, and resident interviews were conducted when possible to confirm appropriate staffing was used.
• Provided education for all newly hired licensed staff and CNAs on reviewing the Kardex prior to providing care and using the appropriate number of staff for bed mobility.