Failure to Provide Adequate Supervision During Resident Transfer Resulting in Injury
Penalty
Summary
The facility failed to provide adequate supervision during transfers for one resident, resulting in an ankle fracture. The resident in question had a history of diabetes, arthritis, and physical debility, and was assessed as severely cognitively impaired with a BIMS score of 0. According to the resident's care plan and Kardex, the resident required assistance from two staff members for transfers. However, on the day of the incident, the resident was transferred by a single nurse aide, contrary to the documented care plan. The nurse aide relied on an outdated census sheet that incorrectly listed the transfer status and did not consult the electronic charting system for the most current information. Following the transfer, the resident was found to have swelling, warmth, and tenderness in the left foot and ankle, which was later confirmed by x-ray to be a fracture. The resident was unable to communicate what had occurred due to cognitive impairment. The facility's investigation substantiated neglect, as the nurse aide did not follow the resident's plan of care, leading to actual harm. Staff interviews and documentation confirmed that the plan of care was not followed during the transfer, resulting in the injury.