Failure to Follow Transfer Orders and Secure Memory Care Unit
Penalty
Summary
A deficiency occurred when a resident with a history of transient cerebral ischemic attack, morbid obesity, and difficulty walking was not transferred according to physician orders. The resident was assessed as moderately cognitively impaired, non-ambulatory, and required the use of a mechanical lift (Sarita) with the assistance of two staff members for transfers. However, the nurse aide care card contained conflicting instructions, and a nurse aide attempted to transfer the resident alone without the mechanical lift. During the transfer, the resident's legs buckled, resulting in a fall and subsequent fractures to the right ankle, confirmed by x-ray. The nurse aide reported confusion regarding the care card instructions and did not seek clarification before proceeding with the transfer. Additionally, the facility failed to ensure that all appropriate doors were secured on the locked memory care unit. Observations revealed that the shower room contained potentially hazardous items and was not secured, the dentist office door was propped open, and the soiled utility room door with a keypad lock had been bypassed and was not locked. The soiled utility room contained bottles of cleaning solution, and staff were unaware that these doors were unsecured. The maintenance director demonstrated how the keypad could be bypassed and acknowledged the need for a more secure lock. Interviews with staff confirmed that the unsecured doors and access to hazardous materials were not in accordance with facility policy, which required all doors on the secured memory care unit to be locked for resident safety. The facility's policy for the memory care unit emphasized maintaining a secure environment to ensure the safety and well-being of residents, but this was not followed at the time of the survey.