Failure to Follow Care Plan for Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, muscle weakness, and total dependence for transfers was not safely transferred according to her Care Plan. The resident was non-ambulatory and required a mechanical lift with two staff for all transfers. Despite these requirements, a CNA transferred the resident without the mechanical lift and without a second staff member, instead performing a manual pivot transfer and body lift. This action was witnessed by other staff, who reported hearing the resident screaming in distress and observed the resident being roughly handled and repositioned in her wheelchair. Following the transfer, the resident was found to have significant bruising on both upper extremities, including a large dark purple bruise on the right forearm extending from above the elbow to the wrist, and a circular bruise on the left forearm above the wrist. The resident, who was confused and unable to verbalize how the injuries occurred, denied pain but appeared fearful and shaken. Multiple staff interviews confirmed that the resident was transferred without the required equipment and assistance, and that the CNA involved was aware of the Care Plan requirements but did not follow them. The incident was reported to nursing and administrative staff, and documentation confirmed the injuries were new and acquired in-house. Staff interviews revealed that the CNA had only two days of training before working independently and was not familiar with accessing Care Plans. Other staff expressed concerns about the CNA's handling of residents and reported the incident to the nurse and DON. The failure to follow the Care Plan and provide adequate supervision resulted in preventable injuries to the resident.