Failure to Provide Adequate Supervision and Safe Handling During Repositioning
Penalty
Summary
A deficiency occurred when a resident with advanced dementia, severe osteopenia, and a history of multiple comorbidities, including PEG-tube dependence and prior bilateral knee and hip arthroplasties, sustained a spiral fracture of the distal right femur during routine repositioning in bed by a CNA. The resident was completely dependent on staff for activities of daily living and ambulation, and was nonverbal, rarely or never understood, and always incontinent. During incontinence care, the CNA reported hearing a popping sound from the resident's right knee while using a one-person assist technique, after which the resident did not vocalize pain but was later found to have swelling, redness, and pain in the right knee. The CNA had previously performed care for the resident independently and was unaware of the subsequent hospital transfer. Following the incident, the nurse on duty was notified and assessed the resident, noting signs of pain and swelling in the right knee. A STAT x-ray was ordered, and pain medication was administered. However, there was a delay in reviewing the STAT x-ray results, as the night shift nurse did not access the provider portal to check for results, citing workload and being the only nurse for 30 patients. The x-ray provider did not call the facility with critical findings during the night shift, and the results were not reviewed until the following morning by the incoming nurse, who then promptly contacted the provider and arranged for the resident's transfer to the hospital. Interviews with staff confirmed that the resident did not fall and that the injury likely resulted from minimal movement due to underlying bone fragility. The facility's policies required prompt notification of changes in resident status and timely review of diagnostic results. The delay in reviewing the STAT x-ray and the use of a one-person assist for a highly dependent, nonverbal resident contributed to the failure to provide adequate supervision and safe handling techniques, resulting in the resident's injury.