Failure to Follow Care Plan for Safe Transfers Results in Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect by not implementing the individualized care plan intervention requiring the use of a mechanical lift and assistance from two staff members for all transfers. The resident, who had diagnoses including dementia and osteoarthritis and was assessed as severely cognitively impaired, had a care plan and Kardex specifying that all transfers should be performed with a Hoyer lift and two staff. Despite these documented requirements, an agency nurse aide transferred the resident alone and without the mechanical lift. The agency nurse aide was not familiar with the resident's specific care needs and was unaware of the care plan interventions, stating she did not know how to access this information in the facility's system. The aide transferred the resident by herself, placing the resident's arms around her and moving her to bed without assistance or the use of the mechanical lift. This action was not observed by other staff, and no other employees were aware of any falls, improper transfers, or injuries until the following morning when the resident complained of leg pain. Subsequent examination and imaging confirmed that the resident had sustained a nondisplaced spiral fracture of the left tibia. The injury was discovered after the resident was found to have redness, swelling, and pain in her lower left leg. The nurse aide involved had previously signed an attestation acknowledging orientation and training on abuse, neglect prevention, and safe transfer procedures, but failed to follow the resident's care plan, resulting in actual harm.