Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure that residents were transferred according to their care plans and therapy recommendations, resulting in unsafe transfers for two residents. One resident, admitted with respiratory failure, muscle weakness, and abnormal gait, required the assistance of two staff for transfers and was not yet assessed for safe toileting transfers. Despite this, a nurse aide attempted to transfer the resident to the toilet alone, causing the resident's knees to buckle and requiring the resident to be lowered to the floor. Occupational therapy confirmed that the resident should have been provided a bed pan until a safe transfer status was established. Another resident, with a history of stroke, Parkinson's Disease, and muscle weakness, also required extensive assistance of two staff for transfers, as documented in the care plan and therapy notes. However, a nurse aide transferred this resident alone in the shower room, contrary to the care plan and physician's orders. This improper transfer resulted in the resident falling and sustaining a fractured left femur, requiring hospital admission for treatment. Interviews with facility staff and review of documentation confirmed that in both cases, staff knowingly failed to follow the prescribed transfer protocols, acting independently rather than with the required assistance. There was also confirmation that the facility did not have a specific policy regarding adherence to therapy transfer orders, relying instead on staff to refer to the electronic care plan.