Failure to Follow Transfer Protocols Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with muscle weakness, Charcot's joint of the right ankle/foot, and a chronic non-pressure ulcer of the right heel experienced a fall from a mechanical sit-to-stand lift. The resident's care plan required transfer assistance of two staff members when using the mechanical lift, and facility policy also mandated two team members for such transfers. However, a nurse aide attempted to change the resident's brief while the resident was positioned in the lift, and did so alone, contrary to both the care plan and facility policy. As a result, the resident slid out of the lift's secure device and fell to the floor. Facility documentation, incident reports, and staff interviews confirmed that the nurse aide did not follow the established care plan or facility procedures, which led to the fall. The Nursing Home Administrator acknowledged that the staff member failed to adhere to the required protocols for resident safety and supervision during transfers, resulting in the incident.