Failure to Provide Adequate Supervision During Resident Transfer Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on two staff members for transfers due to arthritis and other medical conditions, was transferred by a single nurse aide. The resident's care plan, physician orders, and Minimum Data Set assessment all specified the need for assistance from two staff members during transfers and toileting. Despite this, the nurse aide attempted to transfer the resident alone, contrary to established protocols and documented requirements. As a result of this improper transfer, the resident experienced pain in the left lower leg and ankle, which was later diagnosed as a fracture to the left distal fibula. The incident was documented in the resident's clinical record, progress notes, and an incident report. The nurse aide involved acknowledged in a written statement that the resident was in pain and that the transfer caused harm. Interviews with facility staff and review of personnel files confirmed that the nurse aide had received training and competency assessments related to safe transfer methods and adherence to care plans. However, the failure to follow the resident's prescribed transfer protocol led directly to the resident's injury. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing during interviews.