Failure to Follow Transfer Protocols Results in Resident Injury
Summary
The facility failed to protect a resident's right to be free from abuse and neglect by not ensuring staff followed the resident's care plan for safe transfers. On the morning of November 7, two CNAs did not adhere to the care plan that required the use of a mechanical lift with the assistance of two staff members for transferring the resident from bed to wheelchair. Instead, they manually lifted and pivoted the resident, resulting in the resident experiencing extreme pain in his right leg shortly after the transfer. The resident, who was cognitively intact and had bilateral lower extremity impairment, was dependent on staff for all care and was determined to be non-weight bearing. The care plan, revised earlier, specified the need for a mechanical lift due to the resident's physical limitations and safety concerns. Despite this, the CNAs proceeded with a manual transfer, leading to a right distal femur fracture, which was confirmed by an X-ray. The resident was subsequently transferred to the hospital for evaluation. The incident was compounded by a lack of communication and adherence to protocol among the staff. CNA A, who was responsible for the transfer, did not check the resident's transfer status on the Kardex and instead relied on verbal information from another CNA. This oversight, coupled with the decision to proceed without the mechanical lift due to time constraints, directly contributed to the resident's injury. The facility's failure to ensure staff followed the care plan placed the resident and others requiring mechanical lifts at risk for serious harm.
Removal Plan
- Resident #1 was immediately assessed, X-ray completed and pain medication given. He was sent to emergency room.
- CNAs A and B were removed from service immediately and interviewed about the transfer.
- Residents' Plan of Care (POC)/Kardex reviewed prior to receiving care from Nursing Staff.
- Education of staff begun on all shifts regarding the importance of following residents' POC of transfer status and where to obtain transfer status from Kardex.
- 70 day shift staff, 20 evening shift staff, 11 night shift staff provided education that included post test of reporting of any allegation of abuse/neglect/exploitation (ANE), who to report to in facility i.e., abuse coordinator, DON, or supervisor and correlation to failure to provide care as outlined in Plan of Care.
- A group discussion with CNAs to ask what their barriers may or may not be to following POC and the importance of communicating those barriers immediately to their supervisor.
- All residents were reviewed to ensure POC accuracy for transfer.
- Interviews were conducted with 9 residents on the CNA's assignment to verify that staff are consistently following care planned transfer status.
- Interviews were conducted with 41 interviewable residents regarding abuse and neglect to determine any other concerns.
- Any staff member not present were educated prior to starting their shift.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) Meeting held and attended by Administrator, Director of Nursing, Medical Director and Interdisciplinary team to review incident and investigation.
- 13 Clinical Nursing Staff on 7AM-3 PM shift, 8 Clinical Nursing on 3 PM-11 PM shift, and 5 Clinical Nursing Staff on 11 PM-7AM shift provided education regarding the importance of following residents' plan of care of transfer status and where to obtain transfer status from Kardex.
- Another Ad Hoc QAPI meeting with Administrator, Director of Nursing, Medical Director, Company President, Chief Nursing Officer, Regional Plant Operations Director and Interdisciplinary team to review incident and investigation.
- 8 Clinical Nursing Staff on 7 AM-3 PM shift, 6 Clinical Nursing Staff on 3 PM-11 PM shift, and 4 Clinical Nursing staff on 11 PM -7 AM shift provided education regarding the importance of following residents' plan of care of transfer status and where to obtain transfer status from Kardex. Any Clinical Nursing staff member not present received education prior to their shift. Education was continued regarding education of reporting of any allegation of abuse/neglect/exploitation, who to report to in facility i.e., abuse coordinator, DON, or supervisor and correlation to failure to provide care as outlined in Plan of Care.
- An Ad Hoc QAPI meeting attended by Regional Director of Operations, Quality Management Specialist, Nursing Home Administrator and Director of Nursing. Discussion completed to include needed re-education regarding where to find transfer status on the Kardex, ANE continued education review of assignments, review of current status of lifts/batteries. Review of monthly lift inspections- review of interviews and re-enactments.
- Education was continued with staff regarding education of reporting of any allegation of abuse/neglect/exploitation, who to report to in facility i.e., abuse coordinator, DON, or supervisor and correlation to failure to provide care as outlined in Plan of Care. 22 additional staff were provided education.
- Nurse Leadership completed quality monitoring, on all three shifts, to include verbal review and/or return demonstration to ensure following residents' plan of care of transfer status and where to obtain transfer status from Kardex.
- Audits/observations completed of resident transfers, where to obtain transfer status, how many staff needed to transfer - completed on all three shifts.
- Daily room rounds completed with guardian angel rounds- regarding abuse and neglect, observations made regarding transfers.
- Ad Hoc QAPI meeting held included review of education completed, and individual phone calls continued regarding mandatory education needed- staff to sign education and post test prior to working.
- Audits/observations completed of resident transfers, where to obtain transfer status, how many staff needed to transfer, completed on all three shifts.
- Daily room rounds completed with guardian angel rounds-completed with guardian angel rounds- regarding abuse and neglect, observations made regarding transfers.
- Ad Hoc QAPI meeting held-review of education completed, continued individual phone calls continue regarding mandatory education needed- staff to sign education and post test prior to working, discussed need to review Facility Assessment.
- Continued audits/observations completed of resident transfers, where to obtain transfer status, how many staff needed to transfer, completed on all three shifts. Daily room rounds completed with guardian angel rounds- regarding abuse and neglect, observations made regarding transfers.
- Ad Hoc QAPI meeting held-review of education completed, continued individual phone calls continue regarding mandatory education needed- staff to sign education and post test prior to working.
- Ad Hoc QAPI meeting held-review of education completed, continued individual phone calls continue regarding mandatory education needed- staff to sign education and post test prior to working.
- Daily room rounds completed with guardian angel rounds- regarding abuse and neglect, observations made regarding transfers, continued.
- 100% of Nursing staff was trained regarding resident transfer status, where to obtain information on the Kardex, and regarding Abuse and Neglect to include post test- (1 employee out of the country and 1 on family medical leave).
- Monthly QAPI meeting held-Facility Assessment reviewed, education, audits, post test reviewed- IDT has determined compliance. DON/designee will continue to complete random audits/observations of resident transfers to evaluate ongoing compliance. DON/designee will continue to complete random audits/interviews of staff to validate staff can articulate abuse/neglect reporting process.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An agency NA forcefully pushed a wheelchair-bound resident through a doorway while the resident was caught in the frame, causing the resident’s foot to strike both shins and resulting in bruising, swelling, pain, and an acute right tibia fracture. The resident had dementia, muscle weakness, and required assistance with mobility and transfers. CCTV and the facility’s investigation showed the NA did not follow safety measures during the transfer.
A resident with dementia and a history of aggression assaulted another resident in a hallway, pushing him from a chair onto the floor and then attempting to strike him with a chair while a third resident was nearby. Staff on constant observation and another observer did not intervene until after the resident had already been pushed down, despite the resident being on enhanced supervision for prior resident-to-resident altercations. Both residents had severe cognitive impairment, and interviews showed the assigned aide did not understand the urgency of the constant observation role.
Delayed reporting of resident-on-resident sexual abuse allowed continued nonconsensual sexual contact. A resident with schizophrenia and moderate cognitive impairment reported that his roommate kissed, touched, and sexually assaulted him without consent, while the roommate admitted to sexual contact. A nurse aide heard the allegation but did not report it right away, and the unit manager later confirmed the delay.
Failure to respond appropriately to an alleged sexual abuse incident: a resident with intact cognition alleged a CNA raped them during incontinence care, but the resident remained in the facility for hours without a documented medical or psychosocial assessment. The CNA said they provided care and applied ointment to the resident’s groin and vaginal area, while video showed the CNA in the room for 36 minutes. The resident was later tearful, fearful, and distrustful of staff, and the DON and admin did not report the allegation to DOH because the resident later described rough handling.
Failure to Maintain Separation Between Residents With Known Aggression: A resident with a known hx of resident-to-resident physical aggression struck another resident in the head with a cane in the dining room, causing a bump, laceration, and bruising. The assaulted resident was non-ambulatory, dependent on staff for transfers, and had dementia, while the aggressive resident had intact cognition, used a cane, and had a care plan for prior physical altercations. Staff placed the residents in the same area with limited supervision, and the aggressive resident stated the other resident deserved it and that he would hit him again.
A resident with stroke-related diagnoses and cognitive intact status was transferred to the hospital for weakness, dizziness, pallor, and low K+. After the resident was stable for return, the DON and administrator went to the hospital and, along with the owner and corporate administrator on speaker phone, were reported by the resident and hospital staff to have yelled, been rude and aggressive, and told the resident the facility would not take the resident back because of behaviors and money owed. The resident stated feeling pressured, outnumbered, and insignificant.
Failure to Protect Resident During Transfer Resulted in Right Tibia Fracture
Penalty
Summary
The facility failed to protect a resident from abuse and neglect when an agency nurse aide forcefully handled Resident R86 during wheelchair transport. CCTV review showed the aide pulling the resident as she was caught in a doorway, then attempting to push her through the doorway forcefully. During this event, the resident’s right foot became caught on the doorframe and struck her right shin, then her left shin, before she was pushed through the doorway. Resident R86 was admitted to the facility with diagnoses including hypertension, vascular dementia, muscle weakness, and cognitive communication deficit. The resident’s MDS indicated dependence for multiple mobility-related activities and use of a wheelchair. The care plan noted that the resident could move around the facility without supervision but could not exit without supervision, and later documented bruising to both lower extremities, swelling of the lower right extremity, and a right tibia fracture, with bed rest and Hoyer transfers for all transfers. After the incident, bruising was documented on the resident’s lower extremities, including dark purple/green bruising to the right shin and swelling and pain in the right leg. The resident was unable to tolerate range-of-motion assessment because of pain and agitation. X-rays later showed an acute mildly displaced spiral fracture below the level of the tibial prosthetic stem in the right tibia. The facility’s investigation concluded that the nursing aide neglected to follow facility safety measures.
Failure to Prevent Resident-to-Resident Abuse During Constant Observation
Penalty
Summary
The facility failed to protect a resident from abuse when a resident with severe cognitive impairment and a history of aggressive behavior assaulted another resident in the hallway. Resident #1 had diagnoses including unspecified dementia with behavioral disturbance, COPD, muscle weakness, and major depressive disorder, and his MDS coded him with a BIMS score of 3 out of 15. Resident #2 also had severe cognitive impairment, with diagnoses including Alzheimer’s disease with early onset, unspecified dementia without behavioral disturbance, hypertension, and muscle wasting and atrophy, and his MDS also coded a BIMS score of 3 out of 15. During the incident, staff heard a chair flip over and a thud, then found Resident #2 on the floor. A video reviewed by the facility showed Resident #1 standing in front of Resident #2 and pushing him out of a chair and onto the floor. The video also showed Resident #1 picking up a chair and attempting to strike Resident #2 with it while Resident #3 was in close proximity. An OSM sitting nearby observed the incident and did not intervene until after Resident #2 had been pushed to the floor, and the chair was only stopped when the OSM placed a hand on it. The record and interviews showed that Resident #1 had been on constant supervision because of prior aggressive behavior and resident-to-resident altercations. The care plan documented behaviors related to aggression during care and a history of pushing another resident. Staff interviews indicated that the Activities Aide assigned to constant observation was watching the incident but did not intervene quickly, and the aide stated she did not think the situation would become physical and did not know what the constant observation was for. The facility’s policy required staff on constant observation to remain within close proximity to intervene immediately if necessary, but that did not occur during the altercation.
Delayed Reporting of Resident-on-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when continued nonconsensual sexual contact occurred between two roommates. Resident 1 had diagnoses including schizophrenia and a BIMS score of 9, indicating moderate cognitive impairment. Resident 2 had a BIMS score of 15, indicating normal cognitive function. According to the resident’s statement, Resident 2 kissed his body and engaged in sexual contact that Resident 1 did not consent to, including manual genital manipulation, kissing and licking of his body, and anal penetration. A nurse aide heard Resident 1 say that Resident 2 liked to kiss his body and later questioned him about whether Resident 2 asked him to do things he did not want to do. Resident 1 responded that Resident 2 “jerks me off” and said it happened often. The nurse aide stated that he or she was unsure what to do and did not feel comfortable talking to anyone except the unit manager. The unit manager’s statement indicated that the nurse aide reported the allegation four days after the initial disclosure. Resident 2 also acknowledged sexual contact, stating that he had kissed Resident 1 all over his body and touched his private area, and said the last contact occurred two nights before the interview. The resident was evaluated in the ED for sexual assault, and the facility later substantiated sexual abuse based on the delayed reporting by the nurse aide. The report identified that the delay in reporting allowed further nonconsensual sexual contact to occur before the allegation was acted upon.
Failure to Respond to Alleged Sexual Abuse and Assess Resident Distress
Penalty
Summary
The facility failed to protect a resident from abuse, psychosocial harm, and to respond appropriately after an allegation of staff-to-resident sexual abuse. The resident had diagnoses including obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan included psychosocial well-being interventions such as orienting the resident to the environment, introducing compatible peers, and addressing concerns. During incontinence care, the resident alleged that a CNA raped them. The incident report documented that the resident told an LPN they were raped, and the LPN notified a supervisor. The supervisor assessed the resident and noted redness in the perineal area. A nursing progress note later documented that the resident complained of burning in the sacral and vaginal area after incontinence care and that the DON was aware. Video review showed the CNA in the resident’s room for 36 minutes. The CNA stated they provided incontinence care, applied A and D ointment to the resident’s pubis, groin crease, and vagina, and remained in the room because the resident had multiple bowel movements, although the bowel record did not document multiple bowel movements. The resident remained in the facility for about five and a half hours after the allegation without documentation of a medical or psychosocial assessment. Family members reported the resident was hysterically crying, contacted law enforcement, and requested hospital transfer. The resident later stated they felt something enter their anus and vagina, that they told the CNA to stop, and that they became distressed, tearful, fearful, and distrustful of facility staff. The facility concluded abuse did not occur because of conflicting statements, and the DON and administrator stated the allegation was not reported to the state because the resident later described rough handling. The PCP stated the facility should have called law enforcement and the Department of Health if the allegation was rape, and stated a psychosocial assessment should have been completed. The social worker stated they were aware of the incident after it occurred and did not know what interventions should be put in place.
Failure to Maintain Separation Between Residents With Known History of Aggression
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse when one resident struck another resident in the head with a cane in the main dining room. The assaulted resident was non-ambulatory, dependent on staff for bed-to-chair transfers, used a Broda wheelchair, and had diagnoses including non-Alzheimer’s dementia and depression. He had a BIMS score of 12 out of 15 and was documented as having potential verbally aggressive behaviors toward other residents related to dementia. After the assault, he was found with a 5 cm bump and a 1 cm laceration to the left forehead, along with facial bruising, and he stated he felt unsafe around the other resident. The resident who struck him had a BIMS score of 13 out of 15, walked with a cane, transferred independently, and had diagnoses including stroke and depression. His care plan identified a history of resident-to-resident physical aggression and directed staff to monitor for agitation, assist him to a quiet area, and maintain separation from the other resident. Despite that history, he independently approached the other resident in the dining room and struck him multiple times with the cane. During the interview, he stated the other resident deserved it and said he would hit him again if he saw him, indicating the assault was intentional and unprovoked. The investigation also documented a prior resident-to-resident altercation between the same two residents in which the aggressive resident had struck the other resident in the face with his cane several times, causing bruising to the eye and cheek. Staff statements showed the two residents were placed in the same dining area with limited supervision, and staff were occupied with other residents when the assault occurred. Several staff members stated they believed the aggressive resident was simply walking back to his room and did not realize he would attack the other resident. The facility’s investigation concluded that previously identified supervision and separation interventions were not consistently maintained, allowing the aggressive resident to reach and assault the other resident again.
Verbal Abuse During Hospital Discharge Discussions
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse by facility staff. The resident had diagnoses including frontal lobe and executive function deficit, stroke, atrial fibrillation, cerebrovascular accident, and hemiparesis, and the record also documented the resident as cognitively intact. The resident had been admitted on 01/17/2025 and was transferred to the emergency department on 6/18/2026 for further evaluation and treatment related to possible infection, weakness, dizziness, pallor, and low potassium. After the hospital transfer, the resident stated that facility leaders told the resident the facility would not allow the resident to return because there were no available beds. The resident reported that the administrator and DON came to the hospital, that the administrator, DON, company owner, and corporate administrator were on speaker phone, and that the administrator and DON were verbally abusive, yelled at the resident, and said the resident had behavioral issues, owed the facility a lot of money, and was a bad person. The resident stated feeling pressured, outnumbered, and extremely insignificant, and said the resident never told staff not to return until being told the facility did not want the resident back. Hospital staff corroborated the resident’s account. The hospital social worker stated the facility refused to accept the resident back, that the DON was rude, unpleasant, and harassed the resident in the emergency department waiting room, and that the administrator and DON were aggressive and yelled at the resident during the discussion about returning to the facility. The hospital case manager stated the administrator and DON told the resident about problems the resident had caused for the facility and said the resident could return if the resident paid on the bill. The administrator later stated that staff had to yell because the resident was hard of hearing and acknowledged that the conversation involved reviewing the letter and bullet points about what led to the situation.
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