Failure to Follow Transfer Protocols Results in Resident Fall and Fractures
Penalty
Summary
A dependent resident with a history of osteoporosis, lymphoma, breast cancer, previous fractures, and falls was admitted to the facility following a hospitalization for a fall that resulted in a subdural hematoma and right humerus fracture. The resident's care plan specified that she required two or more staff and the use of a mechanical lift for transfers due to her limited mobility, unsteady gait, and high risk for falls. The resident's fall risk assessment categorized her as high risk, noting her inability to walk without assistance and her tendency to overestimate her abilities. On the day of the incident, a nursing assistant (NA) who was unfamiliar with the resident's specific care needs attempted to assist her from bed to the bathroom by ambulating with her, rather than using the mechanical lift and two-person assistance as required by the care plan. During the transfer, the NA let go of the resident to dispose of a brief, leaving the resident unsupported and standing. The resident subsequently lost her balance and fell, resulting in a left wrist fracture and a left hip fracture. The NA later stated she was unaware of the resident's transfer requirements and had been told by other staff that the resident could ambulate with assistance, but could not provide the names of those staff members. Interviews with nursing staff and the physician assistant confirmed that the resident was to be transferred only with a mechanical lift and two staff members due to her poor balance and unsteady gait. The nurse who responded to the fall found the resident on the floor with injuries and confirmed that the care plan had not been followed. The director of nursing also stated that the care plan should have been followed and that the NA should not have left the resident unsupported during the transfer.