Failure to Coordinate Care and Ensure Safe Transfers Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's right to be free from neglect by not coordinating care and services with the hospice provider, resulting in a lack of alignment between the facility's and hospice's written plans of care. The resident, a male with advanced dementia, hemiplegia, a history of falls, and multiple comorbidities, was dependent on staff for all activities of daily living and required a mechanical lift with two-person assistance for all transfers, as documented in the facility's care plan and physician orders. However, the hospice plan of care did not specify the need for a mechanical lift and two-person assistance for transfers. On the day of the incident, a hospice aide attempted to transfer the resident from a shower chair to the bed without using the required mechanical lift or obtaining assistance from facility staff, despite being aware of the resident's transfer requirements. The aide reported being unable to locate the sling for the lift and proceeded with the transfer alone. During this process, the resident fell, sustaining a laceration to the forehead and a cervical fracture. The incident was not immediately reported to the facility's charge nurse, and the hospice aide did not call for assistance before or after the fall. Interviews and record reviews revealed that the hospice and facility staff did not routinely share or coordinate care plans, and hospice staff were not consistently included in care plan meetings. The hospice aide admitted to sometimes transferring the resident without assistance due to lack of available staff or equipment. Facility staff were not always aware when hospice staff were providing care, and there was no established process to ensure hospice staff reviewed the facility's care plan or Kardex before providing care. The facility also lacked a fall prevention policy and procedure at the time of the incident.