Failure to Follow Care Plan for Dependent Transfer After Fall
Penalty
Summary
A deficiency occurred when a resident with diagnoses of schizophrenia, dementia, falls, and impaired mobility was not transferred in accordance with their care plan. The resident, who had severely impaired cognition and was dependent for transfers, was found on the floor by a nurse aide during the night. The care plan required two staff and a mechanical lift for all transfers due to the resident's high fall risk and physical limitations. However, the nurse aide, without checking the resident's transfer status, lifted the resident alone and placed them back in bed without using the required mechanical lift or seeking assistance. The nurse aide did not report the fall to the charge nurse as required. The resident subsequently complained of pain and was found to have a displaced fracture of the left humerus, confirmed by hospital evaluation. Interviews with facility staff, including the Director of Rehabilitation and the Director of Nursing, confirmed that the resident's care plan specified the use of a mechanical lift with two staff for all transfers, and that the nurse aide's actions were not in accordance with facility policy or the resident's care plan.