Failure to Provide Required Transfer Assistance Resulting in Resident Injury
Penalty
Summary
A resident with a history of cerebrovascular accident, hemiplegia, and recent femur fracture was care planned for total mechanical lift transfers with two staff assistance. The resident was dependent for transfers and required a large sling size, as documented in the care plan and supported by therapy and nursing assessments. On the day of the incident, the resident was transferred by a single CNA without a second staff member, contrary to the care plan and facility policy, which required two-person assistance for mechanical lift transfers. During the transfer, the resident fell, resulting in significant pain and an acute left femoral shaft fracture with intra-articular extension to the knee joint, as confirmed by hospital records and imaging. Multiple interviews and documentation revealed inconsistencies in staff and resident accounts, but it was ultimately determined through investigation and reenactment that the CNA performed the transfer alone. The mechanical lift was present in the room, but the required second staff member was not involved in the transfer process. Facility policies on abuse prevention, safe operation of resident lifts, and fall and injury reduction all required adherence to care plans and manufacturer recommendations, including the use of two staff for mechanical lift transfers when indicated. The failure to follow these protocols and provide the necessary assistance directly resulted in the resident's fall and injury, constituting neglect as defined by facility policy.