Failure to Provide Person-Centered Care and Timely Assessment After Transfer Injury
Penalty
Summary
A deficiency occurred when a resident did not receive care and services in accordance with a comprehensive assessment, person-centered care plan, and the resident's choices. The resident, who had multiple diagnoses including Parkinson's Disease, congestive heart failure, and was on hospice care, was assessed to require an EZ-stand and assist of one for transfers. However, a Certified Nursing Assistant (CNA) transferred the resident using a pivot transfer without the EZ-stand, contrary to the care plan. Following this transfer, the resident began experiencing left knee pain, swelling, and hematoma, which was reported to nursing staff. Despite the resident's complaints of pain and visible injury, a thorough assessment including vital signs was not completed after the initial telehealth visit. Orders for pain management and comfort measures were implemented, but there was no imaging performed to rule out a fracture, and documentation shows inconsistent application of topical treatments. The resident's pain persisted, and she began refusing care, meals, and assistance. There was a lack of ongoing, comprehensive assessment and insufficient communication with the resident's physician, hospice, and responsible party regarding the change in condition and the potential need to alter the plan of care. The resident's condition continued to decline, culminating in a further change of condition that required oxygen therapy due to respiratory distress. The responsible party was not promptly notified of the incident or the resident's deteriorating status. The resident ultimately passed away, and an autopsy revealed the primary cause of death was a fracture of the distal left femur. The facility's failure to complete ongoing assessments and communicate findings to appropriate parties resulted in a finding of immediate jeopardy.