Failure to Follow Resident Transfer Plan of Care
Penalty
Summary
Facility staff failed to follow the written plan of care for a resident who was documented as requiring transfer with a mechanical lift and two-person assistance due to confusion, left side weakness, and impaired mobility following a stroke. The resident's care plan and comprehensive assessment indicated substantial to maximal assistance was needed for transfers, and the use of a mechanical lift was specified in the closet care plan. Despite these documented requirements, staff transferred the resident manually without the mechanical lift. The incident occurred when a CNA and an LPN entered the resident's room to transfer the resident from a wheelchair to a bed. The LPN instructed the resident to place their hands around the nurse's neck and attempted to lift the resident out of the wheelchair, but was unable to clear the wheelchair armrest. Multiple attempts were made, during which the resident's feet became caught in the wheelchair foot pedals, and the resident was ultimately lifted over the armrest and onto the bed without proper support. The family member present reported the transfer was performed in a rough manner, resulting in the resident's head and legs being left dangling off the bed before being quickly repositioned by the nurse. Following the transfer, the resident complained of left knee pain and was unable to participate in physical therapy at their previous level for several days. An x-ray showed no acute fracture or dislocation, but moderate osteoarthritic changes were noted. The therapist confirmed the resident's knee pain limited therapy participation temporarily, though the resident returned to baseline function within a week. The facility's investigation, including review of camera footage, substantiated that the staff did not follow the resident's plan of care, as the mechanical lift was not used during the transfer.