Failure to Follow Two-Person Transfer and Lift Requirements Resulting in Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement fall prevention measures and follow the resident’s care plan for transfer assistance. A resident with extensive medical and functional impairments, including cerebral palsy, spastic hemiplegic cerebral palsy, vascular dementia, reduced mobility, prior left fibula fracture, and multiple psychiatric diagnoses, was care planned as dependent for transfers and requiring two-person assistance. Multiple assessments and care plans documented that the resident was at high fall risk and required substantial to total assistance: the post-fall observation assessment identified a high fall risk; Section GG assessments and functional abilities assessments documented that chair/bed to chair transfers and putting on/taking off footwear required two staff assist; and care plans dated 1/8/24, 1/24/25, and 4/30/24 specified moderate to substantial assist x2 with gait belt for all transfers due to increased weakness and behaviors, mechanical Hoyer lift x2 for transfers, and use of a full body lift with two-person assist for all transfers. Despite these documented needs and interventions, on the date of the incident the resident was transferred by only one certified nurse aide from bed to wheelchair. The resident reported that the wheelchair was not positioned correctly, that the aide grabbed her under the arms, stood her up, then let go from her left side, causing her to slide down to the floor. The resident, who had left-sided weakness and was wearing a left Ankle Foot Orthosis (AFO) brace, stated she heard a cracking sound when she slid to the floor and immediately reported leg pain. The facility-reported incident documented that the resident was found sitting on the floor with her back to the bed and legs flat on the floor and that she sustained a left tibia-fibula fracture, for which she was hospitalized and treated. Interviews with staff showed a lack of awareness and adherence to the resident’s care plan and fall prevention interventions. A registered nurse on duty at the time of the fall stated she was unsure of the resident’s transfer status prior to the fall and confirmed that only one staff member assisted with the transfer when the resident fell and sustained a fracture. An LPN stated she was not aware of the fall care plan intervention requiring two-person transfer due to increased weakness and behaviors. Another RN stated that care plan interventions are to be followed for all residents, and the DON and Administrator both stated their expectations that care plans be updated as needed and followed by staff. Facility policies on the Fall Prevention Program and on transfer/manual gait belt and mechanical lifts required assessment of transfer needs, documentation in the care plan, and use of transfer conveyances and mechanical lifts according to the plan of care, but these were not implemented for this resident at the time of the incident.
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