Failure to Follow Safe Transfer Policy and Timely Injury Reporting Results in Resident Harm
Penalty
Summary
Facility staff failed to follow established policy for safe resident handling and transfer, resulting in harm to a cognitively impaired resident who required two-person assistance and a mechanical lift for all transfers. On the day of the incident, two CNAs transferred the resident from bed to a shower chair and then to a wheelchair using manual lifting techniques, rather than the required mechanical lift, despite the resident's care plan specifying the use of the lift with two staff present. Video footage confirmed that the mechanical lift was not used during these transfers, and staff statements corroborated that manual lifting occurred. Approximately three hours after the transfer, one of the CNAs reported the resident's injury to an LPN, who was observed on video assessing the resident's arm but failed to report the incident to administration or document the assessment as required by facility policy. The injury, a comminuted fracture of the right humerus, was not formally identified until the following day when another CNA noticed swelling and bruising and reported it to a different nurse, who then initiated appropriate medical evaluation. The delay in reporting and assessment resulted in a delay in diagnosis and treatment of the resident's injury. Interviews and written statements revealed that the involved staff were aware of the injury and the improper transfer method but chose not to report the incident immediately, with one LPN instructing the CNAs not to disclose the event to avoid disciplinary action. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, suffered actual harm as a result of these failures to adhere to policy and promptly report and document the injury.