Failure to Follow Care Plan During Mechanical Lift Transfer Results in Resident Fall
Penalty
Summary
Staff failed to ensure a resident's right to be free from neglect when two CNAs transferred a resident using a mechanical lift without following the care plan and physician orders, which required a four-person assist for safe transfer. The resident, who had Parkinson's Disease and moderately impaired cognition, was being moved from bed to a transport chair. During the transfer, only two CNAs were present, despite the established requirement for three CNAs and one nurse due to the resident's physical limitations and risk for instability. As a result of this inadequate staffing during the transfer, the resident was seated in the transport chair when it flipped backward, causing the resident to fall to the floor. The resident complained of head pain, though no visible injuries were noted, and was subsequently sent to the emergency room for further evaluation. Both CNAs involved acknowledged awareness of the four-person assist requirement, but one CNA stated that staffing shortages had led to only two people assisting, while the other CNA believed there had been a change in protocol based on a prior meeting. Interviews with facility leadership confirmed that the staff did not provide the necessary care and supervision to ensure the resident's safety during the transfer. The DON and Administrator both acknowledged that the failure to follow the care plan and obtain the required assistance constituted neglect and placed the resident at risk for injury. The incident was reported to the appropriate authorities within the required timeframe.