Failure to Use Proper Transfer Techniques and Notify Physician After Resident Fall
Penalty
Summary
Staff failed to follow professional standards of practice during the transfer and post-fall care of a resident with dementia, morbid obesity, and a history of falls who was receiving chemotherapy. Despite a care plan and physical therapy evaluation directing the use of a mechanical lift for all transfers, staff attempted to transfer the resident manually without a gait belt, instead lifting under the resident's arms. The resident expressed pain and inability to stand during multiple transfer attempts, but staff continued to try to move the resident, ultimately resulting in the resident being lowered to the floor after the legs gave out and the left leg became twisted underneath. After the fall, staff did not immediately notify a Registered Nurse (RN) to assess the resident, nor did they conduct a thorough assessment of the resident's condition prior to further movement. The resident was transferred from the floor to a wheelchair using a mechanical lift, but only after the incident had occurred. The RN who eventually assessed the resident only changed a dressing on a pre-existing skin tear and did not perform a comprehensive assessment of the resident's new complaints or injuries. The resident was then sent to a scheduled medical appointment, where further symptoms were noted, and was subsequently transferred to the Emergency Department, where a tibia/fibula fracture was diagnosed. Facility leadership and staff interviews confirmed that the use of a gait belt is standard practice for transfers and that staff should have stopped the transfer and used a mechanical lift when the resident was unable to stand. The facility also failed to notify the resident's physician of the fall and change in condition in a timely manner, as required by facility policy. The physician only became aware of the incident after being contacted by the hospital. The facility did not have a transfer policy available for review.