Neglect Due to Failure to Follow Two-Person Transfer Requirements
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s care plan and transfer requirements, resulting in a nondisplaced patella fracture. The resident had dementia, was cognitively impaired, and according to an annual MDS and care plan required substantial to maximum assistance and the assistance of two staff for transfers. Facility policy required use of the Kardex in the PCC system at the start of each shift to verify accurate information on transfer status and other care needs. Despite these requirements, a nurse aide transferred the resident alone from bed to wheelchair, believing the resident was a one-person assist and without checking the Kardex or care plan for the correct transfer status. During the transfer, the resident stated, “oh my leg,” but the aide did not observe obvious injury at that time. Later that day, the aide noticed the resident’s knee was red and reported this to the nurse. A nursing note documented that the resident complained of left knee pain with redness, warmth, and slight edema, and subsequent physician assessments noted ongoing swelling, erythema, warmth, and pain with weight-bearing. An X-ray ultimately revealed a nondisplaced patella fracture of unclear cause, as the resident reported no fall. The facility’s investigation, including interviews with the aide and leadership, confirmed that the aide had not accessed the Kardex, did not remember how to access it, and never looked at Kardexes for her residents, and that she failed to follow the resident’s care plan transfer interventions, leading to substantiated neglect associated with the injury.
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