Failure to Follow Two-Person Bed Mobility Care Plan Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment remained as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents. Facility policies required development and implementation of a comprehensive, person-centered care plan and use of a Kardex as a quick reference to each resident’s particular needs, with CNAs expected to provide ADL care according to the resident’s plan of care and Kardex. The resident involved had a history of cerebral infarction with left hemiplegia, aphasia, hypertension, moderate cognitive impairment, and was assessed as dependent for bed mobility, requiring substantial or maximal assistance from two or more helpers to move from lying to sitting on the side of the bed. The resident’s comprehensive care plan, initiated earlier, documented a deficit in ADL function related to a cerebrovascular accident and specified that bed mobility from lying to sitting on the side of the bed required substantial or maximal assistance from two or more staff. Despite this, on the day of the incident, a CNA assisted the resident alone from lying to a sitting position on the edge of the bed without obtaining a second staff member, and did so without reviewing the resident’s Kardex beforehand, relying instead on prior experience caring for the resident. The CNA then left the resident sitting unsupported on the edge of the bed while leaving the room to obtain a mechanical lift and another staff member to assist with the transfer from bed to chair. When staff returned, the resident was found on the floor next to the bed. Nursing assessment documented that the resident reported pain in both hips and was drawing the left leg up to the chest due to pain. The resident was subsequently sent to the hospital, where imaging revealed a left intertrochanteric hip fracture, and the resident underwent an open reduction internal fixation of the fracture. Interviews with the RN, DON, nurse practitioner, medical director, and administrator confirmed that the resident required two-person assistance for sitting on the edge of the bed due to poor trunk control and inability to sit unsupported, and that staff were expected to follow the care plan and Kardex when providing care. The failure to provide two-person assistance for bed mobility and leaving the resident sitting on the edge of the bed unassisted led to the fall and resulting hip fracture.
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