Failure to Communicate Resident Safety Restrictions Leads to Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was cognitively impaired and had a diagnosis of dementia and a sternal fracture, was transferred into a recliner chair by a nurse aide. The resident's care plan and therapy recommendations clearly indicated that she was not safe to sit in a recliner chair. Despite these documented interventions, the nurse aide was unaware of this restriction and proceeded to transfer the resident into the recliner in the TV room. Shortly after being placed in the recliner, the resident was found on the floor in front of the chair, complaining of severe pain under her right arm and chest. She was subsequently sent to the hospital, where an x-ray confirmed a sternal fracture. The incident investigation revealed that the nurse aide had transferred the resident into the recliner less than five minutes before the fall occurred. Further review determined that the care plan intervention regarding recliner safety was not linked to the nurse aide's electronic charting system, making the information inaccessible to the nurse aide. Interviews with facility leadership confirmed that the nurse aide did not have access to the necessary care plan information and was therefore unaware of the resident's restriction regarding recliner use.