Failure to Use Required Mechanical Lift and Two-Person Assist During Transfer
Penalty
Summary
A resident with diagnoses including demyelinating disease of the central nervous system, quadriplegia, and anoxic brain damage was admitted to the facility and had a care plan requiring transfer by mechanical lift with two-person assistance and nurse supervision. Despite these documented requirements, a certified nursing aide (CNA) transferred the resident from a wheelchair to bed alone, without the use of a mechanical lift and without nurse supervision. This incident resulted in the resident experiencing a fall and subsequently sustaining a left shoulder fracture, as confirmed by an X-ray and follow-up by a nurse practitioner. Interviews with the resident and staff confirmed that the transfer was performed by a single CNA without adherence to the prescribed safety protocols. The resident reported hearing a pop and feeling pain during the transfer, later learning of the collar bone fracture. Staff interviews corroborated that the CNA did not use the mechanical lift or have a second person present, as required by the resident's care plan. The incident was documented in the facility's records, and the CNA involved was suspended pending investigation.