Failure to Ensure Safe Transfers by Family Led to Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, left-sided hemiplegia, osteoporosis, and dementia sustained a left arm fracture of unknown origin. The resident required extensive assistance for transfers, as documented in their care plan and physical therapy assessments. Despite these needs, the facility's policy on transferring and ambulation did not address the involvement of non-staff, such as family members, in resident transfers. Family members were known to have transferred the resident between the bathroom, recliner, and bed without staff present or supervision. There was no evidence that the family received any training or education on safe transfer techniques prior to the injury. Multiple staff, including CNAs and LPNs, were aware that the family was assisting with transfers, but there was no documentation of this being communicated to therapy or administration, nor was there a referral for family education before the incident. The resident began complaining of left arm and shoulder pain, which was noted by nursing staff, but there was no documented assessment by a qualified professional on the day of the initial complaint. An x-ray later confirmed an acute fracture of the proximal humerus. The facility's investigation found that both staff and family had transferred the resident, and that the family had not been trained in safe transfer methods prior to the injury. The care plan and facility policies did not address or provide guidance for family involvement in transfers.