Failure to Ensure Safe Transfer Procedures Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severely impaired cognition and total dependence on staff for transfers and mobility sustained a left leg fracture during a transfer. The resident’s care plan specified the use of a full mechanical lift and required two staff members for all transfers. However, on the day of the incident, a Geriatric Nursing Assistant (GNA) attempted to transfer the resident alone, resulting in the resident’s leg becoming twisted and subsequently fractured. Medical record review and staff interviews confirmed that the GNA was aware of the resident’s transfer status but failed to seek assistance from another staff member as required. The incident was discovered when a Physical Therapy Assistant noticed changes in the resident’s leg during a therapy session, which led to further assessment by an LPN and confirmation of the fracture at the emergency department. Further investigation revealed that not all clinical staff had received education on proper transfer procedures following the incident. Attendance records showed that several nurses and GNAs did not attend the post-incident education session, and there was no documentation of disciplinary action for those who missed the training. Additionally, the GNA involved had not received recent education or performance evaluations related to transfers.