Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the prescribed transfer protocol for a resident who required maximum assistance of two staff members and the use of a mechanical lift. The resident, an elderly female with diagnoses including dementia, chronic kidney disease, muscle weakness, cognitive communication deficit, and abnormal gait, was dependent on staff for activities of daily living and required two-person mechanical lift transfers as documented in her care plan and medical records. On the date of the incident, the CNA transferred the resident alone using a gait belt instead of the required mechanical lift, without checking the resident's care summary or consulting with nursing staff regarding the appropriate transfer method. During the transfer from wheelchair to bed, the CNA heard a popping sound, and the resident subsequently complained of pain in her right arm. Assessment by the charge nurse and hospice nurse revealed swelling and pain in the right shoulder, and an X-ray confirmed a displaced fracture of the humeral neck. The resident's care plan, MDS assessments, and active orders all indicated the need for two-person mechanical lift transfers, and interviews with staff confirmed that this was the established protocol for the resident. The CNA admitted to not checking the care summary or asking the nurse about the correct transfer method, despite having received training on these procedures during onboarding. The incident was identified as Immediate Jeopardy due to the failure to provide adequate supervision and assistance devices, resulting in a serious injury to the resident. The event was corroborated by interviews with multiple staff members, review of medical records, and direct observation of the resident's condition following the incident. The deficiency was attributed to the CNA's inaction in verifying the resident's transfer requirements and not adhering to established safety protocols.