Resident Sustains Fracture Due to Improper Transfer by Single CNA
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and required the assistance of two staff members for toileting and transfers as documented in their care plan and on the white board used by nurse aide staff, was transferred by a single Certified Nurse Aide (CNA). The resident, who had diagnoses including arthritis, high blood pressure, depression, and osteoporosis, was alert, oriented, and able to communicate needs. The resident reported pain in the left lower leg/ankle after being transferred by the CNA, who admitted to transferring the resident alone and causing pain during the process. Clinical documentation and staff statements confirmed that the resident's care plan and functional assessment required two-person assistance for transfers due to self-care performance deficits related to arthritis. Despite this, the CNA attempted the transfer alone, contrary to the established plan of care and facility protocols. The resident subsequently sustained a fracture to the left distal fibula, as confirmed by x-ray, after complaining of pain and reporting that their leg had been bumped during the transfer. The incident was identified as neglect, defined by facility policy as the failure to provide goods and services necessary to avoid physical harm. The CNA involved had received training and competencies in safe transfer methods prior to the incident. The failure to follow the resident's care plan and transfer requirements directly resulted in actual harm to the resident, specifically a fractured left fibula.