Failure to Provide Required Supervision During Resident Transfer Resulting in Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with significant mobility impairments from bed to wheelchair without the required assistance of a second staff member. The resident had a history of right hemiparesis, episodes of weakness, and was care planned as a two-person transfer due to a previous right femur fracture and moderate cognitive impairment. Despite these documented needs, the CNA performed the transfer alone, resulting in the resident falling and sustaining a closed displaced spiral fracture of the right femur. The CNA admitted to not reviewing the resident's electronic medical record (EMR) or care plan prior to the transfer and relied instead on informal observations of other staff. Interviews with staff and review of facility policy confirmed that the expectation was for two staff to assist with transfers for this resident. The incident was reported after the fall, and the resident was subsequently assessed and sent to the emergency department for further treatment. The facility's policy emphasized minimizing accident hazards and providing adequate supervision, but this was not followed in this instance, directly leading to the resident's injury.