Failure to Provide Safe, Assisted Transfer Resulting in Leg Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision during a transfer for a cognitively impaired resident with severe dementia, generalized muscle weakness, impaired balance, history of falls, and dependence on staff for transfers and mobility. The resident’s MDS and care plans documented severe cognitive impairment (BIMS score of 4), dependence on staff for wheelchair mobility and transfers, and the need for substantial to maximal assistance with bed mobility, transfers, and ADLs. The care plan further specified that two staff were to participate in repositioning and turning the resident in bed, and that staff were to observe for and report redness, open areas, scratches, cuts, and bruises to the nurse. On the date of the incident, two CNAs attempted to assist the resident into bed while the resident was resisting and hitting staff. One CNA reported that, due to the wheelchair’s “weird” position, the assisting CNA swung the wheelchair toward the bed frame to turn it while the resident’s left leg was positioned behind the right leg at an angle. During this maneuver, the resident’s left knee hit the bed frame, and the resident immediately screamed and yelled that staff had broken her knee, using expletives. The witness CNA stated that the bed frame height aligned with the area of the resident’s later-observed bruise and that the resident’s leg position at the time of impact was as she demonstrated, with the left leg angled behind the right. The witness CNA further reported that, after repositioning the wheelchair, the assisting CNA decided to perform a “hug” transfer of the resident into bed without the witness CNA’s help, and the resident again cried out that staff had broken her knee. The CNAs reported to the nurse that the resident had bumped her leg on the bed frame and cried out in pain. Following the incident, the nurse who was informed the next morning assessed the resident and did not initially observe redness or bruising, and believed the resident’s pain was at baseline, noting the resident had a history of leg pain and frequent refusal of pain medication. Two days after the incident, a CNA reported bruising below the resident’s left knee, and a nurse documented facial grimacing and yelling upon palpation of the lower leg. An x-ray obtained at that time showed an oblique fracture of the proximal tibia and proximal fibula with soft tissue swelling and age-indeterminate fractures. The orthopedic clinic later documented that, although the exact timing and mechanism of the fracture were unclear, there were acute findings on the x-rays, including well-defined fracture lines and absence of healing, and the fracture would be treated as acute. The facility’s own accident policy stated that the environment should be as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents were facility-wide priorities, using a systems approach that considers environmental hazards and individual resident risk factors.
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