F0600

J

Failure to Follow Two-Person Bed Mobility Care Plan Resulting in Hip Fracture

Saint Augustine, Florida Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from neglect by not ensuring that a CNA followed the resident’s care plan requirements for two-person assistance with bed mobility. The resident had an active care plan, revised on 12/23/25, identifying a potential for falls related to seizure history, a history of placing himself on the floor when upset, and raising his bed to the highest position. Interventions included two-person assistance with bed mobility, floor mats on both sides of the bed, and two-person assistance for transfers. A prior nursing progress note dated 11/3/25 documented that the resident had a witnessed fall when a CNA provided morning care alone, turned the resident on his left side, and he slid out of bed onto the fall mat. On 11/4/25, the IDT met and documented that the resident was to have two aides perform care while in bed.

The resident’s medical record showed multiple significant diagnoses, including a displaced intertrochanteric fracture of the right femur (subsequent encounter), peripheral vascular disease, myelodysplastic syndrome, obesity, lymphedema, seizures, major depressive disorder, ADHD, hereditary and idiopathic neuropathy, and rheumatoid arthritis. An annual MDS with ARD 12/09/25 documented a BIMS score of 14/15, indicating intact cognition. Active orders included an air mattress, antidepressant (venlafaxine), gabapentin for neuropathy, Lasix, levetiracetam for seizures, and, following the fall with hip fracture, orders for right hip surgical incision care, morphine for pain, and later a Hoyer lift transfer with two-person assist. These clinical details, combined with obesity and lymphedema, contributed to the need for two-person assistance with bed mobility as reflected in the care plan and staff documentation.

On 2/3/26 at approximately 2:00 PM, CNA A, who normally worked as an Activities Assistant and was assigned to the nursing unit that day due to staffing call-outs, entered the resident’s room to provide incontinent care. CNA A reported that she had not reviewed the resident’s care plan at the beginning of the shift because she arrived at 8:00 AM to find that breakfast trays had already been passed and the previous shift staff had left, and she stated she did not have time to review care plans. She said she briefly asked two CNAs for a rundown of her assigned residents, and they did not mention that this resident required two-person assistance for bed mobility. While providing care alone, she turned the resident toward the window while he held the side rail; his large, heavy legs slipped off the bed, and the weight of his lower body pulled him off the bed so that his lower body was on the floor and his upper body remained elevated as he held the rail. Nursing documentation and LPN B’s interview confirmed that the CNA was alone, that the resident was found with his lower body on the floor in a twisted angle while holding the side rail, and that the resident complained of right hip pain after being assisted back to bed with a Hoyer lift and multiple staff. An x-ray showed an acute transverse fracture of the proximal femur, and the resident was sent to the ER and admitted for surgery. The facility’s abuse/neglect policy defined neglect to include performing one-person assistance when a resident is care planned for two persons and identified failure to implement effective communication systems across shifts as potential neglect, which aligned with the circumstances of this incident.