Improper Transfer by CNA Results in Resident Ankle Fracture
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, muscle weakness, and impaired functional abilities in both lower extremities, who was dependent on two or more staff for transfers and required a mechanical lift, was transferred unsafely. Despite the resident's care plan and facility policy requiring the use of a mechanical lift with two staff members, a CNA independently attempted to transfer the resident by standing and pivoting her into bed without assistance or the proper equipment. This action was not in accordance with the resident's assessed needs or the facility's safe transfer protocols. As a result of this improper transfer, the resident sustained a fracture involving the lateral and medial malleoli of the right ankle, as confirmed by an x-ray. The incident was discovered after the resident was observed with swelling and bruising to the right ankle, and subsequent investigation revealed that no other staff assisted or were asked for help during the transfer. The CNA responsible for the transfer did not follow established procedures and did not seek assistance, directly leading to the resident's injury.