Failure to Follow Two-Person Assist and Safe Transfer Protocols
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to follow the care plan for a resident with anoxic brain damage and reduced mobility, who required two-person assistance for transfers and toileting. During an observed transfer, the CNA assisted the resident alone, using improper technique by pulling the resident by the wrists and allowing the resident to twist toward the bed's edge, with the resident's face briefly resting on the side rail. The resident, who wore ankle-foot orthoses (AFOs), was then assisted to stand using a Sara Steady device and transported to the bathroom, where the CNA again provided assistance without a second staff member present, contrary to the care plan instructions. Additionally, the internal doorway to the resident's room was obstructed by a Hoyer lift, which could have impeded access to the room. The CNA left the resident unattended on the toilet and exited the room, relying on the resident to use the call light when finished. Interviews with the Director of Nursing and other staff confirmed that the resident was always to be assisted by two people for transfers and toileting, and that doorways should remain clear for safety. Facility policy required staff to ensure safe patient handling and clear access during care activities.