Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and follow established transfer protocols, resulting in actual harm to a resident. The resident, who had diagnoses including anxiety, spinal stenosis, muscle weakness, and syncope, required substantial/maximal assistance for transfers and had a physician order and care plan specifying transfer with a mechanical lift and the assistance of two staff members. Despite these documented requirements, the resident was transferred from bed to wheelchair by a single nursing assistant without the use of a mechanical lift. During this transfer, the resident's left shin struck the wheelchair leg rest, causing a 5 cm laceration that required hospital treatment and sutures. The nursing assistant involved stated that the transfer was performed alone because the resident indicated that one person could assist her, and the assistant was unaware of the resident's need for a mechanical lift. Review of facility policies and the resident's care plan confirmed that the transfer should have been performed with two staff and a mechanical lift. The incident was identified as past non-compliance, and interviews with staff and facility leadership confirmed the failure to provide adequate supervision and adherence to transfer protocols, resulting in injury.