Failure to Follow Two-Person Sit-to-Stand Transfer Care Plan Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring a two-person assist with a sit-to-stand lift for transfers from bed to wheelchair. The resident had multiple diagnoses including Parkinson’s disease, Alzheimer’s disease, abnormalities of gait and mobility, muscle weakness, lack of coordination, and osteopenic bone structure. The resident’s MDS showed poor cognition, and clinical documentation on multiple dates indicated that the resident required total assistance of two persons for transfers using a sit-to-stand lift. The resident’s care plan, revised on 10/28/25, specifically documented the need for a sit-to-stand lift with assistance from two staff members for transfers. On 12/24/25, the resident exhibited nonverbal signs of pain, such as grimacing, following a transfer from bed to wheelchair. An x-ray of the bilateral hips and pelvis was ordered and later revealed an acute right femoral neck fracture with mild displacement, while the pelvis and left hip appeared intact and bony structures were osteopenic. Subsequent clinical notes documented the fracture and the resident’s transfer to the hospital for further evaluation and treatment. The facility’s internal investigation, as reported in the Facility Reportable Event submitted to the Department of Health, confirmed that the CNA assigned to the resident on 12/24/25 had transferred the resident independently using a stand-pivot technique. Interviews conducted by the surveyor showed that CNAs and nursing staff were expected to follow the resident’s care plan and care card, which were kept in binders in each resident’s bedroom closet. CNA staff and an LPN stated that transfer status and ADL needs were located on the care plans and that CNAs were expected to check these before providing care. The DON confirmed that the investigation determined there had been no fall and that the CNA did not follow the resident’s care plan, which required a sit-to-stand lift with two staff for transfers. The CNA position description and the facility’s care/service plan policy both required implementation of individualized care plans and documentation and communication of updates to CNAs, underscoring that the resident’s prescribed transfer method was not followed at the time of the incident.
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