Failure to Follow Care Plan for Resident Transfer Results in Fall and Fracture
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) independently transferred a resident who required the assistance of two staff members, as specified in the resident's care plan and functional abilities assessment. The resident, who had mild cognitive impairment, hemiplegia, vascular dementia, chronic pain, osteoporosis, and was non-ambulatory, was being transferred using an EZ stand mechanical lift. The care plan and facility documentation clearly indicated that two staff were required for all transfers due to the resident's history of letting go of the lift handles and periods of unresponsiveness, especially when fatigued. During the transfer, the NA attached the harness and straps to the EZ stand and attempted to help the resident hold onto the handlebars. However, the resident let go of the handles and began slipping out of the harness. The NA, who had only been employed for a few weeks, attempted to retrieve the wheelchair but was unable to prevent the resident from falling. The resident fell to the floor, initially reported shoulder pain, and was later diagnosed with a closed fracture of the proximal end of the right humerus after being sent to the emergency department. The resident's pain was severe, and she required narcotic pain medication and a sling for her right arm. Interviews with staff revealed that the expectation for two-person assistance during transfers was well established in the care plan, care cards, and among experienced staff. The NA involved in the incident was aware of the care plan instructions but stated that other NAs had told her transfers could be done with one person, leading her to believe it was acceptable. Other staff confirmed that the resident's care plan had been updated to require two-person assistance due to her declining strength and tendency to let go of the lift handles. The failure to follow the care plan directly resulted in the resident's fall and injury.