Failure to Follow Care Plan for Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan interventions required for safe transfers of a resident with significant physical impairments. The resident had a history of hemiplegia and hemiparesis following a cerebrovascular event, as well as other chronic conditions including heart failure, COPD, diabetes, and atrial fibrillation. The care plan specified that the resident required assistance of one staff member with a gait belt and two-wheeled walker, with a wheelchair to follow during transfers, and contact guard assist. Despite these directives, the resident was ambulated without the required contact guard assist and without the wheelchair positioned behind her. During a toileting transfer, a new nursing assistant, on her first solo day, was unable to fit the wheelchair into the bathroom with the walker. The assistant attempted to manage the transfer by holding the gait belt while moving the walker and then the wheelchair, resulting in the resident needing to take several unsupported steps. The resident became unsteady and fell, sustaining a comminuted fracture of the proximal humerus. Documentation and interviews confirmed that the care plan was not followed during this transfer, and the wheelchair was not positioned as required. The incident was reported by the nursing assistant, and subsequent documentation indicated that the resident's care plan had not been adhered to at the time of the fall. The facility's policies required staff to follow the care plan or Kardex for transfers, and the failure to do so directly led to the resident's fall and injury. The deficiency was identified through interviews, document review, and progress notes, which all confirmed the deviation from the prescribed transfer protocol.