Failure to Provide Required Two-Person Assistance During Bed Mobility Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and staff assistance to prevent an avoidable fall with major injury for a resident who required two-person assistance for bed mobility. The resident had multiple diagnoses, including a prior displaced intertrochanteric fracture of the right femur, obesity, lymphedema, seizures, neuropathy, and other chronic conditions. The resident’s care plan, revised prior to the incident, identified a potential for falls related to seizure history and behaviors, and specifically required two-person assistance with bed mobility and transfers, as well as floor mats on both sides of the bed. The resident’s MDS showed intact cognition, and the record documented that he was dependent on staff for turning, repositioning, and other ADLs. Prior to the February incident, the resident had a documented fall on a previous date when a CNA provided morning care alone, turned the resident onto his side, and he slid from the bed onto a fall mat. Following that fall, the IDT documented that the resident was to have two aides perform care while in bed. Despite this, on the date of the later incident, an Activities Assistant (CNA A) who was covering on the nursing unit due to staffing call-outs provided incontinent care to the resident alone. CNA A reported that she did not have time to review care plans at the start of the shift, that the previous shift staff had already left, and that the two CNAs she briefly consulted did not tell her the resident required two-person assistance for bed mobility. She also stated she was unfamiliar with the resident and that this was her first time working with him. During the incident, CNA A turned the resident on his side in bed toward the window while he was holding the side rail. Because of his large, heavy legs related to lymphedema and obesity, his legs slipped off the side of the bed, pulling his lower body to the floor while his upper body remained partially supported by the side rail. The resident reported that he was not given instructions or preparation before being turned and that the turn happened quickly, after which he found himself on the floor. LPN B, the assigned nurse, found the resident with his lower body on the floor in a twisted angle and his upper body off the floor holding the side rail. The resident was assisted back to bed with a Hoyer lift and multiple staff, after which he complained of right hip pain. A STAT x-ray was ordered and showed an acute transverse fracture of the proximal right femur, and the resident was subsequently sent to the hospital for further evaluation and surgery. The facility’s own turning and positioning policy required use of two persons for the procedure as needed and explanation of the procedure to the resident, and the person-centered care plan policy required that individualized care plan interventions be entered into the electronic record to guide CNAs in meeting residents’ care needs.
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