Failure to Follow Safe Transfer Procedures Resulting in Resident Fall and Injury
Penalty
Summary
A resident with severe cognitive impairment, a history of falls, and dependence on staff for transfers was involved in an incident where proper transfer procedures were not followed. The resident's care plan required the use of a full mechanical lift with two staff assisting for all transfers, and the environment was to be kept free of hazards, including removing the floor mat prior to transfers. Despite these requirements, a CNA attempted to transfer the resident alone using the mechanical lift and did not remove the floor mat from beside the bed. During the transfer, the CNA operated the lift over the floor mat, which caused the lift to tip over. As a result, the resident fell and sustained a laceration to the forehead, which required suture repair. The incident was unwitnessed by other staff, and the CNA admitted to performing the transfer alone and not moving the mat, despite knowing the correct procedure. Documentation and interviews confirmed that the resident was care planned for two-person assistance and that the floor mat should have been removed prior to the transfer. The facility's policies also required that mechanical lifts be used according to the care plan and that the environment be free of hazards during transfers. The failure to follow these procedures directly led to the resident's fall and injury.