Failure to Follow Dementia Care and Safety Interventions During ADL Assistance Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and interventions were provided during ADL care, resulting in a fall and right femur fracture. On the morning of 1/13/2026, progress notes documented that the resident slid from her wheelchair to a sitting position on the floor while being adjusted in the wheelchair, with no apparent injury and no pain reported at that time; she was assisted back into the wheelchair. Later that morning, the resident complained of right leg pain, was given Tylenol, evaluated by the Nurse Practitioner, and an x‑ray was ordered. That evening, the x‑ray confirmed a supracondylar fracture of the right femur, and an IDT fall note later documented that the resident was sent to the emergency room for evaluation and treatment. The resident had been admitted with diagnoses including Alzheimer’s disease, major depressive disorder, generalized anxiety disorder, schizoaffective disorder, osteoarthritis, and gait/mobility abnormalities. A quarterly MDS dated 1/6/2026 showed a BIMS score of 99, indicating severe cognitive impairment, severely impaired daily decision‑making, continuous inattention with disorganized thinking, and dependence for upper and lower body dressing. Despite this profile, during a telephone interview the CNA who provided care on 1/13/2026 stated that when she entered the resident’s room, the resident was already agitated. The CNA reported that she was putting a pull‑over shirt on the resident while the resident was pushing against her to get the shirt off, and as the CNA continued to push the shirt down, the resident slid from the wheelchair onto the floor on her left side. The CNA stated she called for the nurse, who assessed the resident and found no injury, and the resident was assisted from the floor back into the wheelchair. The CNA further reported that she and another CNA later assisted the resident to the edge of the bed, at which point the resident began complaining of right leg pain and the nurse was notified. The CNA acknowledged she had received education on caring for combative or agitated residents, including in‑services instructing staff to stop care, ensure safety and dignity, and obtain help when a resident becomes combative or agitated. Facility leadership, including the Education Coordinator and DHS, stated their expectation that staff stop what they are doing, ensure the resident’s safety, and seek additional help when a resident is agitated, resistant to care, and unable to be redirected. Facility policies on Occurrences and Dementia Care emphasized assessing risk, implementing appropriate interventions, and using respectful, patient approaches for residents with dementia, but these expectations were not followed during the incident.
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