Failure to Follow Two-Person Transfer Protocol Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of right hemiparesis, weakness, and a prior femur fracture was transferred unassisted by a CNA, despite care plan documentation and the Kardex indicating that two-person assistance was required for all transfers. The resident was dependent on staff for transfers, as documented in the Minimum Data Set (MDS) and care plan, which specifically outlined the need for two staff members to assist with transfers due to the resident's medical conditions and risk of falls. The facility's policy required comprehensive, individualized care plans with measurable objectives and clear assignment of responsibilities, which were in place for this resident. Despite these documented requirements, the CNA transferred the resident alone, resulting in a fall and a closed displaced spiral fracture of the right femur. Interviews with staff confirmed that the expectation was for two-person transfers, and that the Kardex and care plan were to be followed. The CNA admitted to not reviewing the resident's care plan or Kardex, instead relying on informal observations of other staff. The incident demonstrated a failure to provide adequate supervision and to follow established care plans, directly leading to the resident's injury.