Improper Transfer by CNA Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) failed to follow proper transfer procedures for a dependent resident, resulting in a fractured femur. The resident, who had severe cognitive impairment and was dependent on staff for mobility, was left alone in her room in a geri-chair by a family member. The assigned CNA later entered the room and transferred the resident from the chair to the bed without assistance, using an improper lifting technique by placing one arm under the legs and one under the arms. The CNA admitted to performing the transfer alone and acknowledged that the method used was inappropriate and could cause injury, but stated she felt comfortable due to the resident's small size and her own strength. At the time, the resident had a lift pad under her, as staff had previously used a mechanical lift for transfers earlier that day. The resident's care plan and therapy recommendations indicated she required maximal assistance with a stand-and-pivot transfer, and staff were expected to use a mechanical lift if the resident appeared too weak or unstable. Following the transfer, staff discovered the resident had a swollen and painful left hip, which was later diagnosed as a significantly displaced and angulated periprosthetic fracture of the proximal femoral shaft, with severe osteopenia noted. The incident was reported to the DON, who initiated an investigation, and the CNA was suspended pending the outcome. Interviews with staff and review of records confirmed that the CNA did not follow established protocols for safe resident transfers, directly leading to the resident's injury.