Failure to Follow Two-Person Transfer Protocol Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and required extensive assistance of two staff members for all activities of daily living, including transfers, was transferred by a single staff member using a mechanical lift. The resident's care plan and physician orders specifically required two-person assistance for all transfers, and facility policy mandated two staff for all full body mechanical lift transfers. Despite these clear directives, the staff member performed the transfer alone. The incident was discovered after the resident was observed with signs of pain, bruising, and a deformity to the right knee. Subsequent assessment and x-rays confirmed a supracondylar femur fracture. The resident was unable to communicate how the injury occurred due to severe cognitive impairment. Video footage and investigation confirmed that the staff member entered the resident's room alone with the lift and completed the transfer without assistance, directly violating the care plan, physician orders, and facility policy. The staff member involved had previously been deemed capable of performing resident transfers according to her skills checklist. However, interviews and investigation findings established that she failed to follow required procedures, resulting in actual harm to the resident. The deficiency affected one of three residents reviewed for accidents in a facility with a census of 223.