Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan and facility fall protocol, resulting in a serious injury. One resident, who was care planned as a two-person assist for activities of daily living (ADLs), was being changed by only one certified nursing assistant (CNA). During this process, the resident rolled out of bed, sustained a head injury, and required a higher level of care. The resident was later re-admitted with a diagnosis of traumatic subarachnoid hemorrhage, contusion of the left eye, and a history of falls. The incident report confirmed that the transfer was not performed according to the resident's required assistance level. Further review revealed that the CNA involved had previously dropped three different residents during improper transfers. The administrator acknowledged that the CNA had been educated on proper transfer procedures but failed to follow them. Additionally, required documentation related to the incident and accident reports was missing. The facility's policy mandates adherence to transfer status and completion of all necessary documentation, which was not followed in this case.