Failure to Follow Transfer Care Plan Results in Resident Injuries
Penalty
Summary
Staff failed to follow the resident-specific care plan for transfers, resulting in two separate incidents where a resident with significant mobility limitations and a history of falls was not transferred using the required mechanical lift. In the first incident, a single staff member transferred the resident without a lift, despite the care plan indicating the need for a Hoyer lift or sit-to-stand lift, leading to the resident being lowered to the floor and sustaining a right tibia fracture. Documentation and interviews revealed that the staff member was unaware of the resident's transfer requirements due to the absence of a sling and lack of familiarity with the resident. In the second incident, two staff members attempted a stand/pivot transfer from a shower chair to a wheelchair without using the Hoyer lift, as the sling was not properly positioned under the resident. Both CNAs decided to manually lift the resident, resulting in the resident being lowered to the floor and sustaining a right lower femur fracture that required surgical intervention. Interviews with the involved staff confirmed their knowledge of the care plan requirement for a Hoyer lift but indicated they proceeded with a manual transfer due to perceived urgency and inability to reposition the sling. The resident involved had a medical history including spinal stenosis, cervical spine fusion, a history of falls, and lumbosacral disc disorder, and was dependent on staff for all transfers. The care plan and facility policies required the use of mechanical lifts for transfers, and documentation showed inconsistencies and confusion regarding the correct transfer method. The facility's failure to ensure staff followed the individualized care plan for transfers resulted in serious injuries and constituted Immediate Jeopardy, placing the resident and others requiring similar assistance at risk.
Removal Plan
- Resident #1's care plan was updated on the use of a shower bed (instead of a shower chair).
- The facility identified residents who require a Hoyer lift, and care planned these residents to use the shower bed (instead of a shower chair) on shower days.
- Staff in-services and education: a. How to safely place Hoyer slings from various positions, sitting and lying. b. How to reduce injury with an interrupted fall. c. How to lower a patient to the floor and body positioning. d. Timely assessments at time of fall. e. Timely notifications with family communication.
- New Hire orientation to include fall safety and transfer training.
- Complete competencies with all new hires and transfer training with therapy.
- Current employees will complete annual competency checks with return demonstration.