Failure to Follow Transfer Protocols Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan and daily care guide during a transfer, resulting in a fall and injury. The resident, who had a history of falls, cerebral palsy, autistic disorder, osteoporosis, morbid obesity, and moderate cognitive impairment, was care planned for two-person assistance with a mechanical lift for all transfers. Despite these documented requirements, a certified nursing assistant (CNA) attempted to transfer the resident alone and without the mechanical lift, after the resident expressed reluctance to use the lift. During the transfer from wheelchair to bed, the CNA held onto the back of the resident's pants as the resident attempted to stand and pivot, but the resident fell to the floor. The incident resulted in the resident sustaining a right femur fracture, as confirmed by x-ray. The CNA's actions were in direct violation of the resident's care plan and facility protocols, which required two-person assistance and use of a mechanical lift for transfers due to the resident's significant fall risk and physical limitations. Interviews with facility staff, including the LPN, Quality Assurance/Infection Preventionist, Director of Nursing Services, and Executive Director, confirmed that the resident required two-person assistance with a mechanical lift and that the CNA acted alone during the transfer. The CNA was subsequently terminated for failure to follow policy and procedure. The incident was identified as affecting one of four sampled residents reviewed for accidents.