Failure to Prevent Injury and Properly Assess Changes in Condition During Resident Transfers
Penalty
Summary
A deficiency occurred when staff failed to prevent bruising and sling indentations during a mechanical transfer for a resident who was immobile, totally dependent on staff for all ADLs, and receiving hospice care. The resident had multiple diagnoses, including malnutrition, dementia, and a history of fractures. Despite a care plan specifying the use of a small sling for transfers, staff used an incorrect sling size, resulting in red indentation marks on both thighs and a new bruise above the right knee. The resident was observed to be in pain during the transfer, and the sling indentations matched the pattern of the sling used. Documentation confirmed that a small sling was available but not used as directed in the care plan. Another deficiency was identified when a resident with severe cognitive impairment, non-ambulatory status, and bilateral lower extremity contractures sustained a fracture of the right tibia and fibula of unknown origin. The resident was found with right ankle swelling, bruising, and pain, but staff were unable to determine or report how the injury occurred. The resident was unable to move or turn herself, and family members reported that she was bedridden and required a Hoyer lift for transfers. The incident was not promptly or accurately reported by the LPN on duty, who attributed the injury to pressure from the mattress and failed to document a physical assessment or notify appropriate personnel in a timely manner. Interviews and record reviews revealed that the facility lacked a clear nursing assessment policy for documenting changes in resident condition. The LPN did not obtain an order for a boot applied to the resident's foot and did not report the full extent of the injury to the next nurse. The injury was only escalated after a CNA showed a photo of the bruising to the RN, DON, and NHA, leading to further assessment and hospital transfer. The facility was unable to provide an explanation for the injury, and there was no documentation of skin monitoring or assessment at the time the injury was first noted.