Failure to Follow Care-Planned Transfer Status Resulting in Knee Fracture
Penalty
Summary
The facility failed to ensure a resident’s environment was free from accident hazards and that care-planned transfer interventions were followed. An annual MDS for Resident 3 showed cognitive impairment and a need for substantial to maximum assistance with bed-to-chair transfers. The resident’s care plan documented a self-care deficit related to decreased mobility and required assistance of two staff for transfers. Despite this, on the day in question, a nurse aide transferred the resident alone from bed to wheelchair without checking the resident’s Kardex for current transfer status, believing the resident was a one-person assist. The aide reported that she did not know how to access the Kardex on the kiosk and never looked at Kardexes for her residents. Following this transfer, the resident complained of left leg pain during the transfer and later that day had a red, warm, and slightly swollen left knee, which was reported to the nurse. Subsequent physician assessments documented ongoing left knee swelling, erythema, warmth, and pain with weight-bearing as reported by staff, although the resident denied pain at one point. An X-ray revealed a nondisplaced patella fracture of unclear cause, as the resident reported no fall. The facility’s internal accident/injury report concluded that the resident had an acute left knee fracture and that neglect was substantiated. The Nursing Home Administrator and DON confirmed that the nurse aide failed to follow the resident’s care plan transfer interventions, which resulted in the injury.
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