Improper Transfer After Fall With Suspected Hip Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed professional standards for safely transferring a resident after a fall with a suspected hip injury. A complaint intake review by the South Dakota Department of Health noted multiple areas of care, including falls, and subsequent investigation focused on one resident who fell in his room. A CNA reported seeing the resident walking alone, then hearing a noise and finding him on the floor lying on his right side with his walker nearby and the door partially open. The CNA called for a total body mechanical lift and sling to transfer the resident from the floor, and the RN on duty responded to the fall, performed a nursing assessment including vital signs, ROM, and pain assessment, and observed that the resident’s legs were different lengths, making it obvious to her that his hip was broken. Despite the suspected hip injury and the resident’s pain, staff proceeded to place a total body lift sling under him and used the mechanical lift to transfer him from the floor to a medical cart, also changing his soiled incontinence brief while he was in pain during sling placement. The RN later stated she did not remember how the transfer to the medical cart was done, and the electronic medical record and facility-reported incident did not clearly document how the resident was moved from the floor, although the incident report indicated he was assisted off the floor onto a medical cart by a total lift with multiple CNAs and RNs. Another RN described her own practice as completing assessments on the floor, gathering a total body lift and staff, and calling the physician before moving a resident with a suspected head, neck, or hip injury, but this was not the process followed in this case. Interviews with other staff revealed inconsistency and lack of clarity regarding appropriate transfer methods for residents with suspected fractures. The DON stated it was the facility’s process to lift residents with a total body lift even if a suspected injury was present, and identified a nursing skills text as the professional standard used by the facility. In contrast, an RN coordinator with ED experience stated she would not use a mechanical total body lift for a resident with a suspected hip injury, but would instead obtain a hard backboard from the ED and immobilize the injured area, and she would avoid changing a soiled brief unless enough staff were available to immobilize the area. She also reported that most staff did not know what to do or where to obtain a backboard, and she was unaware of any facility policy on transferring a resident with a hip injury. The referenced nursing skills guide included special considerations for maintaining protected straight alignment (logrolling) for certain clients with spinal injuries or surgery, underscoring that the facility’s actual practice in this incident did not align with the professional standards it cited.
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