Failure to Follow Care Plan for Safe Resident Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic brain injury and left-side hemiplegia, who was care planned for two-person assistance and transfer with a mechanical device (Sara lift), was transferred by a nurse aide without the required assistance or equipment. The resident's care plan, nurse aide care card, and quarterly assessment all specified the need for two staff members and the use of the Sara lift for transfers due to the resident's decreased mobility and risk for falls. Despite this, the nurse aide transferred the resident alone and without the mechanical device, which was contrary to the documented plan of care and facility policy. As a result of this improper transfer, the resident sustained a bruise to the upper arm, which was reported to the Director of Nursing the following day. The resident stated that the nurse aide was angry and grabbed the arm during the transfer. The nurse aide admitted to being aware of the care plan requirements but frequently transferred the resident alone because it was easier. The Director of Rehabilitation confirmed that the recommendation for two-person assistance and use of the Sara lift was made for the safety of both the resident and staff.