Failure to Follow Transfer Care Plan Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was dependent for transfers and had a history of right femur fracture and Multiple Sclerosis, was not transferred according to their care plan. The care plan and Kardex specified that two-person assistance was required for transfers using a sit-to-stand lift. However, a CNA attempted the transfer alone, relying on outdated information from a report sheet that did not reflect the updated care plan requirements. During the transfer, the resident's right leg gave out, and although the wheelchair was locked, it moved backward, causing the resident's legs to slide out and resulting in the resident being lowered to the floor and landing hard on their buttocks. The resident immediately began experiencing significant pain in the right thigh, which persisted and worsened over the following days. Initial x-rays did not reveal a fracture, but ongoing pain and subsequent imaging confirmed a femur fracture with callus formation, necessitating surgical intervention. The incident was further complicated by the resident's continued reports of severe pain during movement and care, as documented in multiple progress notes and medication administration records. The failure to follow the care plan for transfer assistance directly led to the resident being injured during the transfer process.