Failure to Follow Care Plan for Safe Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident who required a mechanical lift for transfers. The resident, an elderly female with dementia, osteoporosis, and a healing left femur fracture, was care planned to be transferred using a Hoyer lift due to muscle weakness and an alteration in musculoskeletal status. Despite this, the CNA attempted to transfer the resident from her bed to her wheelchair without the mechanical lift and without assistance, contrary to the documented interventions in the care plan. During the transfer, the resident's legs gave out, and the CNA assisted her to the floor. The resident was then placed back in bed, after which she began complaining of pain in her left leg. The nurse on duty assessed the resident, and due to the extent of pain upon movement and touch, emergency services were called. The resident was transferred to the hospital, where she was diagnosed with a left distal femur fracture that required surgical intervention. Interviews and record reviews confirmed that the care plan specified the use of a Hoyer lift for all transfers, and staff were aware of the resident's transfer status. The CNA involved did not follow the established protocol, resulting in a fall and injury. The incident was self-reported by the facility, and staff interviews indicated knowledge of the importance of following care plans for safe resident transfers.