Failure to Provide Required Two-Person Assistance During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) attempted to transfer a resident from a wheelchair to bed without the required assistance of a second staff member. The resident had a history of atherosclerotic heart disease and traumatic brain injury, and was assessed as non-ambulatory and dependent for transfers, requiring two-person assistance according to the Minimum Data Set (MDS) and physical therapy evaluation. Despite this, the CNA proceeded alone after the resident requested to return to bed, resulting in the resident sliding to the floor in an assisted fall. The resident's care plan and physical therapy assessment both indicated a need for two-person assistance for all transfers due to decreased strength, impaired lower extremity function, and high risk for falls. On the day of the incident, the CNA was aware of the two-person assist requirement, having been informed by a licensed nurse at the start of the shift. However, when the resident requested to go back to bed, the CNA attempted the transfer alone, leading to the resident's gradual slide to the floor and subsequent contact of the resident's head with the floor. Following the fall, the resident was transferred to a general acute care hospital for further evaluation. Interviews with facility staff, including the CNA, registered nurse, and director of nursing, confirmed that the resident required two-person assistance and that the CNA did not follow this protocol at the time of the incident. The facility's fall risk assessment policy also emphasized the need for individualized prevention plans based on resident assessments, which in this case were not adhered to during the transfer.