Resident Sustains Fractured Femur Due to Improper Solo Transfer
Penalty
Summary
A facility failed to protect a resident from neglect, resulting in actual harm. The resident, who had a history of stroke, Parkinson's Disease, and muscle weakness, was assessed as requiring extensive assistance from two staff members for all transfers, as documented in the physician's orders, MDS assessment, and occupational therapy notes. Despite these clear instructions, a nurse aide knowingly transferred the resident alone, without the required second staff member, during a shower transfer. This improper transfer led to the resident falling and sustaining a fractured left femur, which required hospital admission for treatment. The incident was confirmed through facility documentation, staff interviews, and an internal investigation, which established that the nurse aide was aware of the resident's transfer requirements but chose to act alone, directly resulting in the resident's injury.