Failure to Follow Care Plan for Safe Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who had a history of cerebral vascular accident, hemiplegia, hemiparesis, heart failure, and diabetes mellitus, was transferred from a wheelchair to a bed by a nurse aide without the use of a mechanical lift, as required by the resident's care plan. The resident was documented as cognitively intact but dependent on staff for transfers and had range of motion impairment on one side. The care plan specifically indicated the need for a mechanical lift for all transfers. On the day of the incident, the agency nurse aide performed a one-person assist transfer, lifting the resident manually from the wheelchair to the bed. The aide did not use the mechanical lift, despite being instructed by another nurse aide to do so and being informed that assistance was available if needed. The resident reported being picked up and thrown onto the bed, resulting in immediate pain. The aide acknowledged performing the transfer alone and stated that the resident complained of mild pain, which was reportedly relieved with repositioning. Following the transfer, the resident experienced significant pain and swelling in the left knee, which was assessed by nursing staff. The pain persisted despite administration of acetaminophen and other interventions. The resident was eventually sent to the emergency department, where imaging revealed a comminuted and displaced fracture of the distal femur. The incident was confirmed through interviews with staff and review of documentation, which showed that the transfer was not performed according to the resident's care plan and that the required mechanical lift was not used.