Failure to Follow Care Plan for Safe Transfer Results in Resident Injury and Death
Penalty
Summary
A deficiency occurred when a resident, who had a history of Parkinson's Disease, atherosclerotic heart disease, and was on hospice care, was transferred by a CNA using a pivot transfer with assist of one, instead of the care-planned method of using an EZ stand with assist of one. The resident's care plan and assessments clearly documented the need for the EZ stand for all transfers due to substantial/maximum assistance requirements. Despite this, the CNA deviated from the care plan and performed a manual pivot transfer. Following this transfer, the resident complained of severe left knee pain, with swelling and bruising observed. The resident reported to multiple staff members that the EZ stand was not used and that she was dropped during the transfer, with her knee hitting the ground. Facility documentation and staff statements revealed inconsistencies and a lack of clear communication regarding the incident. Initial nursing notes did not document a fall or injury, and the incident was not immediately reported as a fall to hospice or the responsible party. The resident's condition deteriorated over the following days, with increased pain, swelling, and cognitive decline. Family members were not promptly informed of the incident or the resident's change in condition. The facility's investigation was delayed, and there was confusion among staff regarding the events that led to the injury. The responsible party only learned of the incident after observing the resident's decline and inquiring with staff. An autopsy determined that the resident suffered a fracture of the left distal femur related to the transfer, which was identified as the cause of death. The medical examiner concluded that the injury was consistent with a fall or being dropped, rather than a soft tissue injury or minor trauma. The facility failed to ensure adequate supervision and adherence to the resident's care plan, resulting in an accident hazard and a lack of appropriate intervention to prevent the injury and subsequent death.