Failure to Follow Transfer Protocols Resulting 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 Hoyer 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, as the Hoyer pad was not under the resident. Despite Staff A's suggestion to use the Hoyer lift together, Staff B insisted on transferring the resident alone without the mechanical lift, using a manual method. During the transfer, the resident's leg scraped against an exposed, rough part of the enabler bar, resulting in a deep laceration that required seven sutures. The resident reported that two staff were present, but only one performed the transfer, contrary to the care plan. Interviews with other residents revealed similar concerns, with two additional residents stating that transfers were sometimes performed by only one staff member, especially on the evening shift, and that this practice felt unsafe. Staff interviews confirmed that the care plan was not followed during the incident, and the Director of Nursing acknowledged that staff did not adhere to the required transfer procedures for the resident.