Failure to Follow Prescribed Transfer Technique and Communication Protocols
Penalty
Summary
A deficiency occurred when staff failed to assist a resident, who had recently undergone a total left knee replacement and had multiple comorbidities including rheumatoid arthritis, gout, osteoporosis, and muscle weakness, in a manner consistent with the transfer recommendations provided by physical therapy. The resident had a history of post-operative complications and was assessed by physical therapy to require a mechanical lift for transfers, with the possibility of performing an incremental scoot transfer if able. On the evening in question, the resident requested assistance to transfer from her wheelchair to her bed. The nurse aide and nurse involved did not consult the resident's care plan or confirm the appropriate transfer method, instead relying on the resident's statements and their own recollections. The resident refused the use of a mechanical lift and gait belt, and staff proceeded with a stand and pivot transfer, which was not the recommended method for her condition at that time. During the transfer, the resident experienced significant pain and reported a 'pop' in her left knee. Staff did not stop the transfer or seek further direction from the DON or physician when the resident refused the safe transfer technique. The nurse and nurse aide did not ensure the wheelchair was properly positioned, nor did they use the recommended incremental scoot transfer or mechanical lift. After the transfer, the resident continued to experience pain, which she later reported to staff. The nurse did not immediately notify the physician or escalate the situation when the resident's pain persisted and her functional ability had acutely declined. Subsequently, the resident called 911 herself and was transported to the hospital, where imaging revealed a displaced periprosthetic patellar fracture requiring further surgery. Interviews with staff and the resident confirmed that the plan of care was not followed, and there was a lack of communication and verification of the appropriate transfer method. The failure to follow the prescribed transfer technique and to seek further guidance when the resident refused the safe method directly led to the resident's injury.