Failure to Provide Safe Transfer and Adequate Supervision Resulting in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when staff failed to provide a safe transfer for a resident with right-sided hemiplegia and a history of stroke, resulting in a fall and acute fractures of the right tibia and fibula. The resident, who was dependent for transfers and required a total mechanical lift with two-person assistance according to her Kardex, was instead assisted by staff using a stand and pivot transfer. During a transfer from the toilet, one staff member left to retrieve the wheelchair, leaving the resident holding onto an assist rail with her non-functional right hand, while the other staff member was not paying attention. The resident lost her balance, fell onto her right knee, and immediately experienced significant pain. The care plan did not specify the transfer method, and staff did not follow the Kardex instructions for a mechanical lift. After the fall, the resident was returned to bed by staff without being asked if she was hurt, and no immediate assessment or documentation of the incident was completed. Multiple staff interviews revealed inconsistencies in the account of the transfer and the fall, with some staff denying any unusual events and others expressing concern about the resident's instability during toileting. The resident, who spoke only Spanish, was not provided with an interpreter during the incident, which contributed to communication barriers. The injury was not reported to nursing supervisors or documented in a timely manner, and there was a delay in notifying the physician and obtaining appropriate medical evaluation. The resident remained in pain for an extended period before the injury was properly assessed and diagnosed. The lack of adherence to the resident's transfer requirements, insufficient supervision during the transfer, and failure to promptly recognize and report the fall led to a delay in treatment. The resident ultimately required hospitalization for management of her fractures, and the incident was confirmed through interviews with the resident, her roommate, family, and facility staff.