Failure to Ensure CNA Competency in Post-Orthopedic Surgery Transfers
Penalty
Summary
The facility failed to ensure that certified nursing assistants (CNAs) were competent in providing appropriate care and services during resident transfers for two residents who had undergone orthopedic surgery. For one resident with a recent left femur fracture and surgery, records indicated that the care plan required immobilization of the affected joints and assistance with transfers. However, during a transfer observed by a family member, two nurses twisted the resident's left leg, resulting in the resident yelling in pain and subsequently being found to have sustained a new fracture, necessitating a second surgery. The family member reported that the physical therapist had provided specific instructions for safe transfers, which were not followed by the staff involved. Another resident, admitted after joint replacement surgery, had physician orders specifying that two folded pillows should be placed under the heel while in bed and that no pillow should be placed under the knee. Despite these orders, a family member observed that nurses repeatedly placed a pillow under the resident's knee, contrary to the physician's instructions. Interviews with CNAs revealed a lack of knowledge regarding the type of surgery the resident had undergone and the necessary precautions for safe transfers. One CNA incorrectly stated that the resident's leg should be crossed during transfers, which was contradicted by the physical therapist, who emphasized the importance of keeping the legs aligned. A review of staff competency files showed that the facility had not conducted skill competencies for CNAs regarding resident transfers, particularly for those who had undergone hip or knee surgery. The Director of Staff Development confirmed that such competencies were not part of the CNA skill competency list. The facility's policies required staff to follow individualized transfer methods as identified in the care plan and to demonstrate specific competencies necessary for resident care, but these requirements were not met in practice.