Failure to Provide Safe Care During Transfer and Personal Care for a Resident with Dementia
Penalty
Summary
A deficiency occurred when staff failed to provide safe care to a resident with dementia, resulting in the resident sustaining a left humerus fracture. The resident, who was severely cognitively impaired and dependent on staff for activities such as toileting, dressing, and transfers, was known to be occasionally combative and resistive to care due to her dementia. Her care plan included interventions such as approaching her later if she became combative, informing her of care tasks before performing them, and providing care in pairs if she was overly stimulated. On the day of the incident, a CNA transferred the resident from her wheelchair to bed using a full mechanical lift by himself. While providing peri care with the resident on her left side, the resident became combative and began leaning toward the edge of the bed. The CNA attempted to reposition her back to the center of the bed while she was resisting, during which he heard a pop from her arm and the resident cried out in pain. The CNA immediately notified the nurse, who assessed the resident and observed a deformity in her left arm. The resident was subsequently sent to the hospital, where she was diagnosed with an acute spiral fracture of the left proximal humerus. Interviews with staff revealed that the CNA was aware of the resident's combative tendencies but proceeded to provide care alone, contrary to the care plan's recommendation for paired care in such situations. Other staff members, including the LPN and DON, stated that if a resident becomes combative or refuses care, staff should back away and seek assistance rather than continue care. The incident was witnessed by another resident who heard the altercation and the resident's complaint of pain. Documentation and interviews confirmed that the resident's injury occurred during an episode of resistance while care was being provided by a single staff member.