Failure to Provide Proper Care Results in Arm Fracture for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a history of left humerus fracture, dementia, and severe functional limitations was dependent on staff for all activities of daily living, including dressing, bathing, and transfers. The resident's care plan specified that her left upper extremity was non-weight bearing due to a previous humerus fracture, and that a sling should be worn at all times. The resident also had a contracture in her left arm, which was to be handled with care during all care activities. On the morning in question, two agency aides assisted the resident with showering and dressing. According to interviews and a review of video footage by a family member, the aides were observed pulling on the resident's contracted left arm and thigh to turn her in bed, despite her care plan indicating that her arm should not be used for such maneuvers. The resident was heard yelling out in pain during this process and continued to complain of arm pain after being dressed and transferred to her chair. Staff and family members noted that the resident's arm appeared more limp than usual, and a bruise was observed. The incident was not immediately reported to management, and the aides involved were not fully aware of the resident's specific limitations. Subsequent assessment and diagnostic imaging revealed that the resident had sustained a comminuted and impacted fracture of the left humeral head. The injury was discovered after the resident continued to express pain and was sent to the hospital for evaluation. Interviews with staff indicated a lack of communication regarding the resident's care needs and improper handling techniques, which directly contributed to the injury. The facility's investigation confirmed that staff failed to provide care in accordance with professional standards and the resident's care plan.