Failure to Protect Resident from Neglect During Transfer
Penalty
Summary
A resident with bilateral below-the-knee amputations, generalized weakness, and a need for personal assistance was admitted to the facility and assessed as cognitively intact. The resident's care plan and Kardex specified that all transfers required the assistance of two staff members and the use of a sliding board. Despite this, the resident experienced multiple falls, including an incident where a nurse aide, whose identity was not determined, transferred the resident alone using a sliding board and failed to lock the wheelchair, resulting in the resident falling onto the site of his right leg amputation. There was no evidence that new interventions were implemented after previous falls to prevent recurrence. The facility's internal investigation into the March 15 incident was incomplete, lacking witness statements, staff interviews, and a full written account of the event. The facility was unable to identify or hold accountable the staff member responsible for the unauthorized solo transfer. Additionally, the resident experienced three more falls after this incident, and the facility could not provide further documentation or details related to the March 15 event. These actions and inactions resulted in a failure to protect the resident from neglect as defined by facility policy.