Failure to Prevent Abuse During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to protect a resident from abuse during a transfer, resulting in actual harm. The resident, who had a history of dementia, stroke, fractures, and osteoporosis, was care planned to be handled gently, allowed to initiate transfers at her own pace, and required two staff for stand pivot transfers or a mechanical lift if fatigued. The care plan also emphasized monitoring for pain and respecting the resident's resistance to care. Despite these directives, staff attempted to transfer the resident from bed to wheelchair against her will after she repeatedly refused to get up, expressing pain and agitation. Multiple staff statements and documentation revealed that the resident was approached several times throughout the morning and consistently refused to get out of bed. LPNs instructed CNAs to let the resident rest if she refused, but a restorative nurse aide insisted on getting her up for restorative activities. During the transfer, the resident was picked up under her arms without footwear, while she was yelling and striking out. The transfer was performed despite her resistance, and she was placed firmly into her wheelchair, at which point staff heard snapping or cracking sounds. Immediately after, the resident exhibited abnormal movements and vocalizations, prompting staff to seek medical attention. Hospital records confirmed the resident sustained a displaced left femoral neck fracture. Staff interviews and documentation indicated that the transfer was not performed according to the resident's care plan or her expressed wishes. Additionally, there were concerns about the integrity of the incident investigation, as one CNA reported that his original statement was altered by the DON to minimize the severity of the incident. The failure to follow the care plan and respect the resident's refusals directly led to the injury and constituted abuse as defined by regulatory guidelines.