Failure to Follow Safe Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure staff used safe transfer techniques for a resident who required assistance from two staff members for transfers, as documented in her care plan and Kardex. The resident, who had moderate cognitive deficits, Parkinson's Disease, and was totally dependent on staff for toileting and transfers, was assisted by only one staff member when getting off the toilet. During this transfer, the resident lost her balance, her foot slipped, and she was lowered to the floor, resulting in a twisted and swollen ankle with significant bruising and pain. The incident report and staff interviews confirmed that the agency staff member did not follow the care plan instructions requiring two-person assistance for transfers. Prior to the incident, the resident was able to ambulate with two staff, a gait belt, and a walker, but after the injury, she required the use of a standing mechanical lift for all transfers. Staff interviews revealed a lack of orientation and communication regarding the resident's transfer needs, with one CNA stating she was unaware of the requirement for two-person assistance and had not received a report from the previous shift. The facility's policy required interventions to be resident-specific and based on assessment findings, but these were not followed in this case, leading to the resident's injury.