Failure to Follow Transfer and Alarm Orders for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and the residents’ plans of care for two residents reviewed for accidents. For one resident with mild cognitive impairment, peripheral vascular disease, diabetes mellitus, and anxiety, the MDS showed severe cognitive impairment and a need for substantial/maximal assistance with transfers. Physician orders and the resident’s care plan required use of a Hoyer (mechanical) lift with two staff for all transfers out of bed to a tilt‑in‑space custom wheelchair. Despite these orders and the facility policy requiring two staff for Hoyer transfers, a nursing assistant performed a Hoyer lift transfer alone after being told by a nurse that assistance would be provided later, and transferred the resident into the custom wheelchair without a second staff member present. Following this solo transfer, the resident, who had reported bilateral lower extremity pain during morning care and was wearing geri‑sleeves for skin protection, again reported bilateral lower extremity pain. The facility’s reportable event documentation identified that during the transfer the resident’s left leg struck the left leg of the custom wheelchair, resulting in a 2 cm open hematoma that later was documented as a 9 cm coagulated hematoma. The resident was subsequently sent to the hospital for evaluation and followed by a wound physician. Interviews with the Director of Therapy and nursing leadership confirmed that the resident’s plan of care and facility policy required two staff for Hoyer lift transfers and that the transfer had been completed by one staff member, contrary to the physician order and care plan. For a second resident with dementia, osteoporosis, repeated falls, and major depressive disorder, the MDS showed severe cognitive impairment and a need for substantial/maximal to dependent assistance with transfers. Physician orders and the care plan required a motion sensor alarm to be in place and on at all times when the resident was in bed, with a bedside sensor and a corresponding alarm box at the nursing station to alert staff to attempts at independent ambulation. On the morning of the incident, the resident was later found sitting on a bathroom floor complaining of right arm pain and was diagnosed with a non‑displaced right clavicle fracture. Facility documentation and interviews indicated that multiple staff did not hear any alarm sound, one nursing assistant was unaware of a sensor alarm in the room, and subsequent investigation determined that the alarm box at the nursing station and the motion sensor alarms were in the off position at the time of the fall, contrary to the physician order and the resident’s care plan.
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