Failure to Follow Care Plan Results in Resident Injury During Transfer
Penalty
Summary
A deficiency occurred when a resident, who had a history of stroke, hip fracture, and osteoporosis, and was care planned for total mechanical lift transfers, was manually transferred by nursing assistants using a stand pivot technique. The resident was severely cognitively impaired and required maximal assistance for mobility, with transfer instructions specifying the use of a mechanical lift. During the attempted transfer, the sling was not properly positioned under the resident, and the nursing assistants were unable to reposition it while the resident was in a reclining wheelchair. Despite the care plan and transfer status requiring a mechanical lift, the nursing assistants decided to proceed with a manual transfer, supporting the resident under her armpits and by her pants. During this manual transfer, a popping sound was heard from the resident's right knee, and she immediately reported pain. The incident was reported to nursing staff, and the resident was subsequently sent to the hospital, where imaging confirmed a non-displaced fracture of the proximal tibia-fibula. The resident returned to the facility with a knee immobilizer and new pain management orders. Interviews with staff revealed that the decision to manually transfer the resident was made due to concerns about the resident slipping out of the improperly positioned sling and the perceived risk of using the lift in that state. The nurse aides did not notify a nurse for assistance with repositioning the sling or for guidance on how to proceed safely, as required by facility policy. The manual transfer was not in accordance with the resident's care plan or transfer status, and the incident resulted in significant injury to the resident.