Failure to Follow Transfer Protocol Results in Resident Fracture
Penalty
Summary
A resident with a history of muscle weakness and difficulty walking was care planned to require a two-person transfer using a mechanical lift for all transfers, as documented in the clinical record and care plan. On the day of the incident, nurse aides attempted to use two different mechanical lifts to transfer the resident from a wheelchair to bed, but both lifts were not functioning. The aides requested assistance from a licensed nurse, who, upon entering the room, observed the resident seated on a lift pad in the wheelchair with the non-functioning lift nearby. Due to the limited space and the lift not working, the licensed nurse decided to perform a one-person manual transfer, contrary to the resident's care plan requirements. Following the transfer, the resident reported hearing a pop in the shoulder but initially felt okay once in bed. Over the next two days, swelling and bruising developed on the resident's left upper arm and lateral breast area. The injury was reported to nursing staff, and subsequent assessments revealed pain, swelling, and discoloration. The resident consistently reported to multiple staff members that the injury occurred during a manual transfer by a male caregiver who lifted the resident under the arms because the mechanical lift was not working. An in-house x-ray was inconclusive, and the resident was sent to the emergency room, where imaging confirmed an acute comminuted fracture of the proximal left humerus. Interviews with staff confirmed that there were two mechanical lifts per floor and that extra batteries were available in the medication room. The licensed nurse involved admitted to performing the manual transfer because the lift's battery was not charged and did not attempt to locate another battery. The facility's failure to follow the resident's care plan for mechanical lift transfers resulted in actual harm, specifically a left humeral fracture, constituting neglect as defined by facility policy and regulatory requirements.