Improper One-Person Transfer Without Gait Belt Leads to Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required two-person assistance for transfers was transferred per protocol, resulting in a preventable accident and an acute comminuted fracture of the left distal femoral shaft. The resident had diagnoses including osteoarthritis of the knee, rheumatoid arthritis, and generalized anxiety disorder, and was non-ambulatory at baseline. An annual MDS showed a BIMS score of 12/15 with some memory deficits, partial assistance needed for bed mobility and transfers, and wheelchair use for mobility. Therapy staff and the DON confirmed that, at the time of the incident, the resident required an assist of two for stand-pivot transfers with a walker per the care card and physician’s order. On the day of the incident, the resident reported feeling very tired and falling asleep in the wheelchair, with left foot discomfort. A nurse aide observed the resident leaning forward in the wheelchair with hands on the side rail and believed the resident was trying to stand. Although the aide knew the resident required two-person assistance and a walker for stand-pivot transfers, she did not call for help, did not use the call bell, did not apply a gait belt, and did not use the walker. Instead, she assisted the resident to stand while the resident held the side rail and instructed the resident to pivot toward the bed. As the resident attempted to pivot on the left leg, both the resident and the aide heard a pop or grinding sound from the left knee, and the resident experienced immediate pain. The aide then maneuvered the resident onto the edge of the bed and into bed without a fall occurring. Following the incident, the resident complained of pain with movement of the left leg and knee. The 3–11 PM RN supervisor assessed the resident around 4:15 PM but did not observe redness or swelling and did not immediately notify the provider. Later that evening, after the charge LPN reported swelling and continued pain, the RN supervisor reassessed the resident and contacted the provider, who ordered a STAT left knee X-ray, ice, and continued PRN Tylenol. The X-ray obtained early the next morning showed an acute comminuted fracture of the distal shaft of the left femur, and the resident was subsequently transferred to the hospital, where surgical intervention with open reduction internal fixation was performed. The incident was documented on the facility’s reportable incident form as occurring during a transfer performed by the 3–11 PM nurse aide, with a pop sound heard and increased left knee pain, and was identified as a preventable accident reflecting a breakdown in supervision and adherence to established protocols.
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