Failure to Follow Transfer Protocols Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and required the assistance of two staff members, was transferred by a single CNA. The resident had significant medical conditions, including COPD, heart failure, and diabetes, and was non-weight bearing on the left lower extremity. The resident's care plan and Kardex clearly indicated the need for a two-person assist for all transfers, and the facility's policies required staff to follow these directives to prevent harm. During the transfer from wheelchair to bed, the CNA performed the transfer alone, contrary to the resident's documented needs. As a result, the resident sustained a deep skin tear on the right shin, which was discovered after the transfer when the resident's pants were removed. The wound was significant, measuring 4.5 cm by 5 cm by 1 cm, with exposure of adipose tissue, and required 17 sutures at the hospital. The incident was attributed to the resident's leg striking the wheelchair leg rest holder during the improper transfer. Staff interviews confirmed that other nurse aides were able to describe how to access and follow a resident's required transfer status. The Nursing Home Administrator acknowledged that the facility failed to protect the resident from neglect, as the CNA did not check the transfer status on the Kardex and did not provide the required level of assistance, resulting in actual harm to the resident.