Failure to Follow Care Plan During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan during a staff-assisted transfer, resulting in a fall and subsequent fracture. The resident, who had diagnoses including Alzheimer's disease, vascular dementia, and osteoporosis, was non-ambulatory and had a care plan requiring the use of a full body mechanical lift (EZ lift) with assistance from two staff members for transfers due to being non-weight bearing on the right lower extremity. Despite this, a nursing assistant attempted a pivot transfer without a gait belt, believing the resident could stand independently, and did not consult the resident's Kardex or care plan prior to the transfer. During the transfer, the resident's legs became weak, and the staff member assisted her to the floor. Initially, no injuries were noted, but the resident later developed pain, swelling, and bruising in the right foot. An x-ray confirmed a slightly displaced fracture of the distal fibula. The resident reported significant pain following the incident, and her family was notified. Interviews revealed that the nursing assistant had not worked regularly at the facility and did not review the care plan or use a gait belt as required by facility policy. Other staff members confirmed that the resident's transfer status had recently changed and that staff were expected to review each resident's Kardex before providing assistance. The facility's policy required verification of transfer status and the use of appropriate equipment, such as a gait belt or mechanical lift, based on the resident's care plan. The failure to follow these protocols directly led to the resident's fall and injury.