Failure to Follow Transfer Protocols Results in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order requiring the use of a mechanical lift for all transfers of a resident with significant mobility and orthopedic issues. The resident, who had diagnoses including osteoarthritis, rheumatoid arthritis, osteoporosis, and a periprosthetic fracture around a right knee prosthesis, was documented as non-weight bearing on the right lower extremity and required total staff assistance for transfers and showers. The care plan and physician's order specifically mandated the use of a Hoyer lift with a green sling for all transfers. Despite these clear directives, three nurse aides transferred the resident from her wheelchair to a shower chair without using the mechanical lift. Witness statements from the aides confirmed that they were aware of the requirement to use the lift but chose to manually transfer the resident instead. The aides cited reasons such as time constraints and the resident's position in the wheelchair, and one aide admitted to not wanting to upset coworkers. During the transfer, the resident experienced severe pain and reported feeling as though her leg was giving out. She subsequently complained of right leg pain, which was documented by nursing staff. An X-ray revealed a comminuted fracture of the right tibia and a displaced fracture of the right fibula, necessitating hospital transfer and surgical intervention. The facility's internal investigation substantiated that the aides knowingly failed to implement the required safety protocols, directly resulting in serious physical injury to the resident. The incident was classified as neglect, as the staff did not provide the necessary goods and services to avoid physical harm, as required by facility policy and physician orders.