Failure to Follow Transfer Protocols and Use Safety Equipment Results in Resident Fall and Multiple Fractures
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments, including Erb's paralysis, hemiplegia, and a high risk for falls, was not transferred according to the physician's order, rehabilitation screen, and nurse aide assignment card. The resident was assessed to require the assistance of two staff members for stand-pivot transfers, as documented in the care plan, therapy screens, and assignment sheets. However, on the day of the incident, only one staff member, an LPN, assisted the resident during a transfer to the bathroom. The LPN was unaware of the required level of assistance and did not use a gait belt, despite facility policy mandating its use for all transfers requiring physical assistance. During the transfer, the resident's foot became caught on the lip of the bathroom floor, resulting in a fall that caused multiple fractures, including to the right tibia, malleolus, and humerus. The incident was witnessed, but the LPN was unable to prevent the fall. Interviews and documentation revealed inconsistencies and confusion among staff regarding the resident's required level of assistance, with some staff believing only one person was needed, despite clear orders and assignment sheets specifying two. The care assignment was not posted in the resident's room, and gait belts were not consistently available or used by staff. Further review showed that the facility lacked a specific transfer and ambulation policy, and staff did not consistently refer to or follow physician's orders or rehabilitation recommendations. The facility's fall prevention and gait belt policies required identification of fall risks and the use of gait belts for all assisted transfers, but these were not adhered to in this case. The failure to provide adequate supervision, follow prescribed transfer protocols, and use required safety equipment directly led to the resident's fall and subsequent injuries.