Failure to Implement Care Plan for Safe Resident Transfer
Penalty
Summary
The facility failed to consistently implement a comprehensive care plan for a resident with multiple diagnoses, including scoliosis, unsteadiness on feet, dementia, and a history of fractures and falls. The resident was assessed as having moderate cognitive impairment and required staff assistance for activities of daily living, including transfers, for which the care plan specified the use of a mechanical stand-up lift with two staff members. Despite this, on the day of the incident, a CNA attempted to transfer the resident without the stand-up lift and without a second staff member, resulting in the resident falling to the floor. The incident occurred when the CNA, believing the resident could bear weight and pivot, assisted the resident from bed to wheelchair without following the care plan's specified interventions. During the transfer, the resident's shoe slipped, causing the resident's legs to give out and leading to a fall. The CNA admitted to not using the stand-up lift and was uncertain if she had reviewed the care plan prior to providing care that day. Other staff, including another CNA and an LPN, confirmed that the resident was care planned for two-person assistance with a stand-up lift and that this protocol was not followed during the incident. As a result of the improper transfer, the resident sustained an acute fracture of the right femur, confirmed by radiology and requiring orthopedic consultation. Interviews with facility staff, including the DON and compliance officer, revealed that staff are expected to review and follow care plans for all residents, particularly regarding transfer methods. The facility's policy requires that care plan interventions be implemented as written, but in this case, the specified transfer protocol was not followed, directly leading to the resident's injury.