Failure to Follow Individualized Transfer Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to follow a resident's individualized transfer plan as recommended by Physical Therapy. The resident, who had a history of osteoporosis, muscle weakness, reduced mobility, abnormal posture, dementia, and functional quadriplegia, was assessed as requiring a sit-to-stand lift for all transfers. The care plan and physical therapy discharge summary both specified the use of this assistive device, and the resident's transfer status was posted on the outside of the room door. On the day of the incident, the LPN encountered the resident in the hallway, addressed a complaint of leg pain, and later assisted the resident in transferring from a wheelchair to a recliner. Instead of using the required sit-to-stand lift, the LPN attempted a manual transfer by grabbing the resident's pants and hips. During the transfer, the resident's legs buckled, and the resident fell into the recliner, landing on their right arm. A certified nurse aide (CNA) responded to calls for help and assisted in completing the transfer, at which point both staff members noticed the resident's arm appeared injured. Subsequent evaluation by a nurse practitioner and hospital staff revealed that the resident had sustained a dislocation and an acute fracture of the right arm, requiring surgical intervention. Interviews with staff confirmed that the LPN was aware of the resident's need for a sit-to-stand lift but failed to use it, stating that she forgot in the moment. The director of nursing and therapy director both confirmed that the resident's care plan required the use of a mechanical lift for transfers, and that the LPN did not adhere to this protocol at the time of the incident.