Failure to Specify Transfer Assistance and Accurately Care Plan Post-Fracture Splint
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized comprehensive care plan that clearly specified transfer assistance needs, including the required number of staff for mechanical lift transfers, for a resident who was dependent on staff for transfers. The resident, admitted with diagnoses including cerebral palsy, lower extremity DVT, muscle weakness, lumbar compression fracture, and other conditions, was cognitively intact and required a sit-to-stand mechanical lift and maximal assistance of two staff for all transfers per occupational therapy assessments. The resident’s ADL care plan and Resident Care Card, which were to guide direct care staff, documented that the resident required physical assistance to dependence with transfers but did not indicate the number of staff required or that a mechanical lift with two staff was needed, despite facility policy requiring two staff for mechanical lift transfers. On the evening of the incident, an agency CNA working his first shift at the facility received report that the resident required a sit-to-stand lift for transfers and acknowledged he knew that such transfers required two staff. Although another CNA on the unit told him that the resident required two-person assistance with the sit-to-stand lift and offered to help, the agency CNA proceeded to transfer the resident alone using the sit-to-stand lift. During this transfer, the resident let go of the hand supports and slid out of the lift sling onto the floor. The resident reported that there had always been two staff present for prior sit-to-stand transfers and that on the day of the fall a single male CNA transferred them without assistance. Nursing staff documented and reported that the resident fell from the sit-to-stand lift during the transfer and complained of left ankle pain. Following the fall, the resident was evaluated in the emergency department and diagnosed with fractures of the distal left tibia and fibula, and a short leg fiberglass splint with an Ace wrap was applied with orders for non-weight-bearing status and to keep the splint on. Subsequent orthopedic consultations directed that the splint remain in place and that the resident remain non-weight-bearing. However, the resident’s updated care plans and Resident Care Card inaccurately documented that the resident had a CAM boot to the left lower extremity when out of bed, with interventions to encourage use of the CAM boot and to check circulation, sensation, motion (CSM) and skin integrity while the boot was on. Multiple nurses, including the DON, confirmed that the resident did not have a CAM boot but instead had a fiberglass splint with an Ace wrap, and staff were unable to locate any CAM boot for the resident. The DON acknowledged that the care plans were not accurate, had not been updated after the orthopedic consults, and should have reflected the fiberglass splint and appropriate interventions, goals, and outcomes related to the fracture and splint care.
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