Failure to Follow Physician's Order for Transfer with Adaptive Device
Penalty
Summary
A deficiency occurred when a resident with dementia, osteopenia, osteoarthritis, anxiety, and muscle weakness, who was assessed as requiring moderate assistance with transfers and the use of a rolling walker, was not transferred according to the physician's order. The resident's care plan and physician's order specified that transfers should be performed with the assistance of one staff member and a rolling walker. However, a nurse aide transferred the resident from a chair to a bed using a stand and pivot technique without the rolling walker and without additional staff present. The nurse aide also reported that the rolling walker had not been in the resident's room for some time and had not been used for transfers recently. Following this transfer, the resident was found to have swelling, pain, and bruising in the left lower leg, with decreased range of motion and guarding behavior. An x-ray revealed a fracture of the left tibia and fibula shaft, and the resident was subsequently sent to the emergency department. Interviews with facility staff confirmed that the transfer was not performed in accordance with the physician's order, and the required adaptive device was not used.