Failure to Follow Two-Person Transfer Protocol Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident who required assistance from two staff members for transfers. The resident, who had severely impaired cognition and no upper extremity impairment at the time of the initial assessment, was involved in an incident where a staff member repositioned and lifted the resident under the arms without assistance from a second staff member and without using a gait belt, as required by policy and the resident's care plan. This resulted in the staff member hearing a pop and the resident complaining of pain in the right arm, which was later diagnosed as a broken right humerus. The care plan for the resident clearly indicated the need for two-person assistance during transfers, and this requirement was accessible to all staff. Despite this, the staff member admitted to being aware of the two-person assist requirement and the need to use a gait belt but did not follow these procedures. The incident was documented in an incident report and confirmed through staff interviews and review of the resident's care plan and assessments.