Failure to Provide Required Two-Person Assist During Standing Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow established safety measures requiring two-person assistance for a dependent resident while standing at a handrail, which resulted in a fall and left hip fracture. The resident was admitted with dementia, anxiety, colon cancer, and osteoporosis, and an MDS assessment showed the resident was dependent for transfers, changing position in bed, and toilet use. A physician’s order and a physical therapy recommendation directed that the resident be assisted by two staff members while standing at a handrail for toileting. Despite these orders, facility documentation revealed that the resident was left standing, holding onto a handrail bar, while a single staff member attempted to put on an incontinence brief. According to the nurse’s progress note and incident documentation, after a shower the nurse aide stood the resident at a grab bar in the main bathroom/shower room and, while attempting to apply a brief and dry the resident, the resident’s hand slipped from the bar and the resident fell to the floor. The nurse responding to the incident observed that one of the resident’s legs appeared shorter than the other and the resident complained of pain, and subsequent communication with the hospital confirmed a broken hip requiring transfer for further treatment. During an interview, the Nursing Home Administrator confirmed that the resident required assistance of two staff members while standing at a handrail and that the nurse aide did not obtain the required second staff member, leading to the fall.
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