Failure to Follow Care Plan During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when facility staff failed to follow a resident's care plan during a transfer, resulting in the resident sustaining a right lower leg fracture. The resident, who had severe cognitive impairment and was dependent on staff for all transfers and activities of daily living, was care planned to require a mechanical lift with the assistance of two staff members for all transfers. Despite this, a nursing aide attempted to transfer the resident using only a gait belt and without the required mechanical lift or a second staff member present. The aide was not aware of the resident's transfer requirements and did not check the care plan prior to the transfer, stating that they did not have time to look up the information. During the transfer, the aide was unable to safely move the resident and had to lower them to the floor. At the time, no immediate signs of injury were noted, and the resident was assisted back to bed. However, the following morning, the resident was found to have swelling, bruising, and pain in the right ankle, which was subsequently diagnosed as a fracture of the distal tibia and fibula. The resident's care plan and facility policy both clearly indicated the need for mechanical lift transfers with two staff, and this information was accessible in the electronic medical record and care plan documentation. Interviews with staff revealed that the majority were aware of the proper procedures for transferring residents who require mechanical lifts, including the need for two staff members and the prohibition of using gait belts for such residents. The aide involved in the incident admitted to not checking the care plan and not being familiar with the resident's specific needs. Other staff present at the time confirmed that the correct transfer method was not used, and that the aide had been advised to use the mechanical lift but did not comply.