Failure to Follow Care Plan for Safe Transfers Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan and safety precautions for a resident who required a full-body mechanical lift with two-person assistance for transfers. The resident, who had diagnoses including chronic obstructive pulmonary disease, kidney disease, neuropathy, and fragile skin, was admitted for short-term rehabilitation and had moderate cognitive impairment. The care plan and Kardex both specified the need for a mechanical lift and two staff members for all transfers due to the resident's decreased mobility and generalized weakness. On the day of the incident, the resident requested to return to bed. Staff A, a CNA, sought assistance from Staff B, another CNA, after noticing the Hoyer lift pad was not under the resident. Despite Staff A's suggestion to transfer the resident together, Staff B insisted on performing the transfer alone without the mechanical lift, using a manual method that involved putting her arms around the resident and standing her up. During this transfer, the resident's leg scraped against an exposed, rough part of the enabler bar, resulting in a deep laceration that required seven sutures. Interviews with other residents who required mechanical lifts revealed that transfers were sometimes performed by only one staff member, particularly on the evening shift, and that this practice was perceived as unsafe. Staff interviews confirmed that the care plan was not followed during the incident, and the Director of Nursing acknowledged that staff had failed to adhere to the resident's transfer requirements.