Failure to Follow Transfer Care Plan Resulting in Arm Fracture
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident free from accident hazards and to provide adequate supervision and assistance during transfers, specifically by not following the resident’s care plan requiring a mechanical lift. The resident had a history of stroke with right-sided weakness/paralysis, speech difficulty, obesity, cognitive communication deficit, arthritis pain, generalized muscle weakness, difficulty walking, and restlessness and agitation. A quarterly MDS documented moderately impaired cognition, functional limitations in one upper extremity and both lower extremities, and dependence on assistance for transfers. The resident’s care plan, last reviewed in January, directed staff to use a Hoyer lift with two staff for transfers in and out of bed and wheelchair, to follow protocol and policy when using the lift, and to use two-person assist with repositioning. On the morning of the incident, the resident was in a wheelchair without a Hoyer sling under them. A CNA later received a request from a family member to put the resident back to bed. The CNA, seeing no sling, assumed the resident might now be a one-person assist for transfers and did not review the care plan or ask other staff about the resident’s transfer status. The CNA applied a gait belt and attempted to transfer the resident from the wheelchair to the bed alone, contrary to the care plan that required a Hoyer lift with two staff. As the resident sat on the edge of the bed, they began to slide down, and the CNA grabbed the resident from the front, under the arms, to prevent them from sliding to the floor. During this maneuver, the CNA reported hearing a crack while holding the resident, and then called for the nurse, who assisted in getting the resident back into bed. Initial nursing assessment noted no head injury and only mild redness to the mid-back without skin tears or bruising, and the resident complained of generalized pain for which PRN Tramadol was given. Later, the resident complained of pain and decreased mobility in the left shoulder, leading to an x-ray of the left humerus that showed a possible fracture. The resident was sent to the hospital for evaluation and returned with the left arm in a sling, continuing to show signs and symptoms of pain during care. Interviews with multiple staff confirmed that the resident should have been transferred with a Hoyer lift and two staff, and that staff were expected to follow the care plan or consult a nurse if unsure of a resident’s transfer status.
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