Failure to Provide Needed Care and Services Following Transfer-Related Injury
Penalty
Summary
A resident with multiple comorbidities, including Parkinson's disease, chronic kidney disease, osteoarthritis, and dependence on oxygen, sustained an abrasion and bruise to the right foot during a transfer from wheelchair to bed by a CNA. The incident was not immediately reported, and the initial assessment by nursing staff did not result in a wound treatment order for the abrasion. The resident later developed increased pain and signs of infection in the right foot, which progressed to cellulitis, requiring antibiotics and wound care intervention. The care plan was not updated to reflect the new injury or to implement additional interventions for safe transfers, despite the incident and subsequent deterioration of the wound. Documentation and follow-up were inconsistent. There was no ongoing weekly skin assessment of the right foot abrasion after it was first identified, and the wound was only seen once by a wound care physician. The wound care provided did not always match the physician's orders, and at one point, the resident was observed without a dressing on the affected foot. The facility's policies required weekly documentation of non-pressure skin alterations and care plan updates in response to changes in resident condition, but these were not followed. Staff interviews revealed that the CNA involved in the incident had not received documented transfer training, and the care plan coordinator could not recall updating the care plan after the injury. The incident investigation and root cause analysis did not result in new interventions to prevent recurrence, and the care plan was not revised to address the resident's increased risk for injury and skin breakdown. Facility protocols for incident reporting, care planning, and skin integrity management were not adhered to, contributing to the deficiency in providing needed care and services according to the resident's plan of care and professional standards.