Failure to Provide Required Two-Person Assist Resulting in Hip Fracture
Penalty
Summary
The facility failed to protect a resident from neglect by not following established care plan and physician/PT orders requiring two-person assistance while the resident was standing at a handrail/grab bar. The facility’s abuse/neglect policy defines neglect as the failure to provide goods and services necessary to avoid physical harm, including failure to follow the resident’s plan of care. The resident, admitted with dementia, anxiety, colon cancer, and osteoporosis, had a care plan and physician/PT directives indicating the need for assistance of two staff members when standing at a handrail for transfers and toileting. Despite these orders and care plan interventions, the resident was assisted by only one nurse aide during post-shower care while standing and holding onto a grab bar. According to facility documentation and staff statements, the nurse aide showered the resident, then stood the resident at a grab bar in the shower room and attempted to apply an incontinence brief while the resident was supported only by the grab bar and a single staff member. During this process, the resident’s hand slipped from the bar, and the resident fell to the floor. A nurse responding to the incident found the resident on the bathroom floor, noted one leg appeared shorter than the other, and documented the resident’s complaint of pain. Subsequent communication with the hospital confirmed that the resident sustained a left hip fracture requiring surgical repair. The Nursing Home Administrator confirmed that the resident required two-person assistance at the handrail and that the nurse aide did not obtain the required second staff member, resulting in the fall and injury.
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