Failure to Follow Care Plan for Safe Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with chronic heart failure and polyosteoarthritis, who required assistance with activities of daily living, was not provided the required level of staff support during a transfer. The resident's care plan and physician's orders specifically mandated the use of a Hoyer lift with two staff members for all transfers. Despite this, a nurse aide performed a transfer alone, citing the absence of available staff at the time. During the transfer, the nurse aide attempted to reposition the resident's legs and heard a crack. The resident, who was cognitively intact, later reported pain and swelling in her left knee. Subsequent assessment and hospital evaluation confirmed a left tibial periprosthetic fracture, requiring immobilization and pain management. The resident experienced significant pain, necessitating frequent administration of oxycodone for relief. The incident was corroborated by witness statements, clinical documentation, and interviews with the resident and staff. The nurse aide admitted to being aware of the two-person requirement for Hoyer lift transfers but proceeded alone due to staffing constraints. This failure to follow the individualized care plan and physician's orders resulted in actual harm to the resident in the form of a serious fracture.