Failure to Follow Transfer Orders Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of deep vein thrombosis and anxiety, who required assistance of two staff members for stand pivot transfers and ambulation only with therapy, was transferred by a single nurse aide (NA). Physician orders, the resident's care plan, and the NA care card all specified that two staff were required for transfers. Despite these clear directives, the NA attempted to transfer the resident alone from bed to chair using a rolling walker. During the transfer, the resident's knee gave out, resulting in the resident twisting their leg and being lowered to the floor by the NA. The resident was subsequently unable to move their right ankle or knee due to pain and was transferred to the hospital, where imaging confirmed an acute mildly displaced fracture of the distal fibula. The incident report and facility investigation confirmed that the resident required two-person assistance at the time of the fall, and that the NA did not follow the established plan of care or verify the transfer status prior to attempting the transfer alone. Interviews with facility staff and the resident confirmed that the NA believed only one person was needed for the transfer and did not check the care card or physician orders. The Director of Rehabilitation and the DON both acknowledged that the NA failed to follow the prescribed plan of care, which directly resulted in the resident's injury.