Failure to Honor Resident's Right to Refuse Mechanical Lift Transfer
Penalty
Summary
Staff failed to respect a resident's right to refuse care when they disregarded his expressed refusal to be transferred via mechanical lift following his return from dialysis. The resident, who had a history of right hip osteoarthritis, left foot amputation, and other significant medical conditions, was assessed as cognitively intact and dependent on staff for transfers. Despite the resident's clear verbal refusal and complaints of pain during the transfer, two CNAs proceeded with the mechanical lift transfer, citing the resident's care plan and safety concerns as justification. During the transfer, the resident experienced significant right hip pain, described as bone-on-bone friction, and expressed emotional distress and loss of dignity. The resident reported that he attempted to stop the transfer and communicated his wishes to staff, but his objections were ignored. After the transfer, there was no documentation of staff providing pain assessment, pain medication, or follow-up care, and the resident stated that no one checked on him or addressed his pain. Interviews with facility staff, including CNAs, therapy staff, and nursing leadership, revealed a lack of documentation regarding the resident's refusal and the education provided about transfer options and risks. The care plan did not reflect the resident's preferences or recent changes in his condition prior to the incident. Staff training records showed gaps in recent in-service education on resident rights. The facility's policy emphasized resident autonomy and the right to refuse care, but this was not upheld in practice during the incident.