Failure to Implement Care Plan for Safe Transfer Results in Resident Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, consistent with the resident's rights and needs as identified in the comprehensive assessment. The care plan specified that the resident, who had dementia, osteoporosis, and a history of left femur fracture, required the use of a Hoyer lift for all transfers due to muscle weakness and inability to bear weight. Despite this, a CNA attempted to transfer the resident without the mechanical lift, contrary to the care plan instructions. During the transfer, the resident's legs gave out, and the CNA lowered her to the floor. The resident was subsequently assessed by nursing staff and began complaining of pain in her left leg after being returned to bed. Emergency services were called due to the extent of her pain, and the resident was transferred to the hospital, where she was diagnosed with a left distal femur fracture requiring surgical intervention. Interviews and record reviews confirmed that the care plan intervention requiring a Hoyer lift for transfers was not followed at the time of the incident. Staff statements and documentation indicated that the resident's care plan was clear about the need for mechanical lift assistance, but this directive was not implemented, resulting in a fall and serious injury.