Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
Staff failed to protect a resident's right to be free from abuse and neglect by not following the resident's care plan for safe transfers. The resident, who had hemiplegia, hemiparesis, obesity, chronic lower back pain, and muscle weakness, was dependent on staff for transfers and required the use of a mechanical lift with assistance from two staff members. Despite this, two CNAs manually lifted and pivoted the resident from her wheelchair to her bed, disregarding the care plan and the presence of a mechanical lift sling already under the resident. During the manual transfer, the resident complained of severe pain in her left leg and was lowered to the floor. The CNAs then lifted her from the floor and placed her in bed without using the mechanical lift. The resident continued to express extreme pain, but neither CNA reported the incident or the resident's complaints to a nurse. The resident later informed another CNA of her pain, who reported it multiple times to an LPN, but the LPN did not assess the resident until nearly seven hours later. An X-ray performed the following day revealed a fractured tibia. The facility's investigation confirmed that the CNAs were aware of the resident's transfer requirements and chose to ignore them. The LPN also failed to respond promptly to the resident's complaints of pain. The actions and inactions of the CNAs and the LPN resulted in a serious injury to the resident and constituted neglect, as defined by the facility's policy. The incident placed not only the affected resident but also other residents requiring mechanical lifts at risk for serious harm.
Removal Plan
- Resident was assessed by the nurse due to her complaint of pain in left lower extremity, provider was notified and order received for diagnostic imaging.
- X-ray was performed and results were received which showed a proximal tibia fracture with mild displacement.
- Resident's physician was notified of the abnormal X-ray results and orders were received for a leg immobilizer and an outpatient orthopedic physician consult.
- A knee immobilizer was placed to resident's left leg as ordered.
- Resident and roommate were interviewed by the former DON and reported that resident was transferred without the use of the mechanical lift by two CNAs.
- The facility initiated an investigation.
- The ADON began education on identifying resident's transfer status, safe transfers and skills validation.
- An Ad Hoc QAPI meeting was held with the facility Administrator, Director of Nursing and Medical Director to review the incident including physician orders obtained related to the resident's fracture. Resident's individualized plan of care including outpatient orthopedic consult and leg immobilizer deemed appropriate by the Medical Director. Discussed staff training to be conducted as a result of incident.
- The CNA who assisted the assigned CNA performed a reenactment of the incident and provided a statement which included information that the two CNAs had knowledge of resident's transfer status and subsequent disregard by performing a stand and pivot transfer. Resident's care plan and Kardex indicated she required two person assistance with the use of mechanical lift for transfers.
- Each resident's care plan and Kardex were reviewed to ensure accurate transfer status was reflected.
- As part of the investigation process, residents were interviewed by the Social Services Director to determine if there were additional concerns of abuse or neglect with no findings.
- The facility held an ad hoc QAPI meeting to review the progress of education and competency completion as well as quality reviews. The committee conducted a root cause analysis which determined the assigned CNA made an independent decision, chose to ignore her prior education and did not follow the resident's plan of care for safe transfers. The ad hoc QAPI committee including the Medical Director approved the recommendations.
- Resident was seen by the provider. Her pain regime was reviewed and adjusted. The facility scheduled an orthopedic appointment as per the physician order.
- The former DON discussed transfer options to the hospital with resident.
- The former DON spoke to the resident and resident voiced wanting to go to the hospital.
- Resident was sent to the emergency room for evaluation due to uncontrolled pain related to the fracture. The resident returned to the facility.
- Resident's provider was contacted, and pain regimen was reviewed and adjusted.
- Nursing staff were educated on change in condition to include but not limited to accidents resulting in injury, offering resident to be transferred to higher level of care for further evaluation if serious injury, escalation to chain of command via nurse supervisor and/or DON if resident concern is not addressed, following resident care plan/Kardex, safe resident handing, mechanical lift usage and competencies. The remaining nursing staff members to receive education prior to next shift worked.
- Facility staff were educated on abuse, neglect and exploitation by the Administrator, Staff Development Coordinator and Nurse Managers. The remaining staff members to receive education prior to next shift worked.
- Ad Hoc QAPI meetings were completed with Medical Director, Administrator, and former DON where incident, abuse and neglect, use of mechanical lifts, transfer competencies, updating care plans/Kardex, change in condition, pain management and following care plans/Kardex were discussed. No recommended changes were made to the performance improvement plan.