Failure to Verify Transfer Status Results in Resident Injury
Penalty
Summary
Two certified nursing assistants (CNAs) failed to verify the required transfer method for a resident who was dependent on staff for transfers and required a mechanical lift with two-person assistance, as documented in her care plan. Both CNAs were unfamiliar with the resident's specific needs and did not consult the electronic kiosk or care plan to confirm the appropriate transfer method. Instead, they transferred the resident using a draw sheet, both from bed to wheelchair and later from wheelchair back to bed, without using the required Hoyer lift. The resident, who had significant medical conditions including Parkinson's Disease, a history of falls, a left artificial knee joint, and a right below-knee amputation, was also severely cognitively impaired and unable to advocate for herself. After being transferred back to bed by the CNAs, the resident yelled out in pain. An x-ray was ordered, revealing a closed displaced fracture of the proximal end of her left humerus. She was subsequently sent to the emergency room for evaluation and treatment, and upon return, continued to experience pain and required her arm to be immobilized in a sling. Interviews with the involved CNAs confirmed that neither had checked the resident's care plan or the electronic system to verify the required transfer assistance prior to performing the transfer. Both CNAs admitted they should have checked the resident's transfer status. The Director of Nursing and other staff confirmed that the resident's care plan clearly indicated the need for a Hoyer lift with two-person assistance for all transfers, and that the staff did not follow this plan, resulting in the resident's injury.