Failure to Follow Safe Transfer Procedures Results in Resident Injury
Penalty
Summary
Staff failed to follow established safe transfer procedures for a resident with significant mobility and cognitive impairments. The resident, who had diagnoses including heart failure, chronic pain, and cognitive communication deficit, was care planned for transfers using a full body mechanical lift with two-person assistance due to an inability to stand or assist with transfers. On the morning of the incident, a staff member transferred the resident from bed to chair using the mechanical lift but did so alone, without the required second staff member present. Later that same day, two staff members transferred the resident from a Broda chair back to bed without using the mechanical lift at all, instead performing a manual two-person lift. Both staff members admitted in interviews that they did not follow the care plan or facility policy, which required the use of a mechanical lift with two-person assistance for this resident. The staff could not provide a valid reason for not using the lift, with one stating she was following the other's lead and another citing being in a rush. As a result of these actions, the resident sustained a 10-centimeter bruise to the left lower leg, experienced pain rated up to seven out of ten, and required both Tylenol and Hydrocodone-Acetaminophen for pain management. The injury was discovered during routine rounds, and subsequent investigation by the facility determined that the bruise was most likely caused by the improper manual transfer. The failure to adhere to the resident's care plan and facility policy directly led to the resident's injury.