F0689

J

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 ensure that staff followed a resident’s care plan requiring two-person assistance for Activities of Daily Living (ADL) care, resulting in a fall and right hip fracture. The resident had multiple significant diagnoses, including cerebrovascular disease, a stage IV sacral pressure ulcer, malignant neoplasm of the breast, chronic pain syndrome, atrial fibrillation, and was receiving palliative care. The active care plan, revised in October 2025, documented that the resident had an ADL self-care performance deficit related to multiple conditions and required substantial/maximal assistance of two staff for bed mobility and dependent/total assistance with transfers using a mechanical lift with two staff and a medium pad. The care plan also identified the resident as being at risk for falls or fall-related injury due to impaired mobility and decreased safety awareness, and included interventions such as a bariatric mattress, bed in lowest position, bolsters, a left side mobility bar, and cues for safety awareness.

On the date of the incident, the resident’s ADL care was provided by one CNA instead of two, contrary to the care plan. A review of the CNA task list from early December through early January showed that the resident had been documented as receiving one-person ADL assistance on 21 of 31 days reviewed, despite the care plan specifying two-person assistance for bed mobility and transfers. On the morning of the fall, a newly hired CNA (CNA B) reported that it was her first day of work and that she was being coached by another CNA (CNA A). When they entered the room, CNA A directed CNA B to care for the other resident in the room while CNA A cared for the resident with the two-person assistance requirement. CNA B pulled the privacy curtain and began providing care to the other resident. While doing so, she heard a thud and then heard CNA A exclaim that the resident was on the floor. When CNA B looked out from behind the curtain, she saw CNA A running toward the resident’s bed from the doorway, and observed the resident on her back toward her right side with her head toward the top of the bed; the bed was in a high position, and the resident was complaining of right hip pain.

Further interviews and documentation clarified the circumstances of the fall. CNA B stated that she and CNA A had not reviewed the Kardex prior to entering the room and that, as a new employee, she did not know how to access the Kardex at that time; she later learned that the resident was obese and required two people for transfers and bed mobility. An LPN familiar with the resident reported that the resident was totally dependent for care by two staff members and confirmed that she was assigned to the resident on the day of the fall. The LPN stated that CNA A had asked her to obtain a wound dressing because the resident’s dressing was soiled, and while the LPN was getting the dressing, she heard CNA A yell that the resident was on the floor. The LPN found the bed raised and the resident lying on the floor between the beds, initially on her right side and then rolled to her back, with her head close to the wall and her hands on her head; the resident complained of head pain and stated she had hit her head. The resident was assisted back to bed with a mechanical lift and multiple staff, and shortly thereafter complained of severe right hip pain. Subsequent SBAR documentation, radiology reports, and hospital emergency department notes confirmed that the resident had sustained a mildly displaced right femoral neck fracture with femoral shaft impaction and an acute sub-capital fracture of the right femoral neck after being dropped by staff during a transfer, while taking Eliquis for atrial fibrillation and reporting right hip pain.

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 plan to be implemented.
• Initiated and completed neglect education for licensed nurses and CNAs regarding proper positioning of residents in bed during routine care, wound care, and repositioning, with emphasis on abuse and neglect, and obtained staff signatures prior to the staff's first shift.
• Completed assessments to determine which residents required assistance with ADL care while in bed, proper positioning during care, and the number of people required to assist during care while in bed.
• Completed a comparison to ensure all residents' care plans and Kardexes accurately reflected residents' bed mobility needs and the number of staff required to assist.
• Initiated competencies for licensed nurses and CNAs in providing ADL care and repositioning residents during ADL care while in bed.
• Conducted an ad hoc QAPI meeting with 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 of the incident were addressed and in substantial compliance.
• Initiated ongoing monitoring of CNA documentation to ensure it matched the Kardex, visual confirmation that the appropriate number of staff provided care, and resident interviews when possible to confirm appropriate staffing was used for care.
• 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.