Failure to Follow Transfer Protocols Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for transfers was not safely or properly transferred according to their care plan. The resident, who required a mechanical lift and two staff members for transfers, was instead moved by a single CNA using a pull sheet from the bed to a shower stretcher. During this transfer, the shower stretcher moved away from the bed, causing the resident to fall to the floor and sustain a left upper extremity humeral fracture. The incident was witnessed after a nurse heard yelling and found the resident on the floor, with the CNA present in the room. The resident involved had multiple medical diagnoses, including heart disease, end stage renal disease, diabetes, and osteoporosis, and was assessed as being completely dependent on staff for transfers. The resident's care plan specifically required the use of a mechanical lift and two-person assistance for all transfers. Documentation in the facility's records, including the Minimum Data Set and assignment sheets, confirmed these requirements. Other staff interviews confirmed that the standard procedure for mechanical lift transfers was to have two staff members present, and that this information was clearly communicated to CNAs through assignment sheets and the electronic medical record. Despite these established protocols, the CNA involved in the incident did not follow the resident's care plan and attempted the transfer alone, without the mechanical lift or a second staff member. The facility's policies also required two staff for mechanical lift transfers. The failure to adhere to these procedures directly resulted in the resident's fall and injury.