Failure to Follow Care Plan During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis following a stroke, severe protein-calorie malnutrition, a history of falls, and contractures was not provided care according to their individualized care plan. The care plan and Kardex specified that the resident required an extensive two-person assist for transfers due to limited physical mobility and right-sided weakness. Despite these documented requirements, a certified nurse aide (CNA) transferred the resident alone using a bear hug technique, rather than with the assistance of a second staff member as required. As a result of this improper transfer, the resident reported hearing a pop in the right shoulder and experienced pain and tenderness. An immediate x-ray confirmed a subcapital humeral fracture. Facility investigation, including staff and resident interviews, substantiated that the CNA did not follow the care plan, leading to actual harm to the resident. The facility confirmed that the transfer was not performed according to the resident's care plan, resulting in the injury.