Improper Manual Transfer Resulting in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired, legally blind, and had bilateral upper and lower extremity impairments, was transferred from bed to wheelchair without the use of a mechanical lift as required by their care plan and physician orders. The resident was fully dependent on staff for transfers and had an order specifying the use of a Hoyer lift with two-person assistance. Despite these documented requirements, a Certified Nursing Assistant (CNA) manually lifted the resident by placing his arms under the resident's legs and back, transferring the resident to a wheelchair without the mechanical lift or a second staff member present. Following this improper transfer, the resident began to display left hip pain and was subsequently assessed by a nurse practitioner. An X-ray revealed a non-displaced fracture of the left femoral neck, and the resident was admitted to the hospital for surgical repair. The CNA initially denied any concerns with care or transfers but later confessed to the improper transfer during the facility's investigation. The facility's policy clearly required the use of mechanical lifts with two staff members for such transfers, which was not followed in this incident.