Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
A resident with a history of hemiplegia, diabetes, and previous falls was admitted and readmitted to the facility, requiring total assistance from two staff members and a mechanical lift for transfers and for moving from lying to sitting. The resident's care plan and Kardex both specified the need for two or more helpers for all transfers. Despite these documented requirements, a CNA attempted to transfer the resident alone by sitting her at the edge of the bed while waiting for help. The force of this action caused the resident to slide forward, resulting in her falling to the floor and sustaining a left humerus fracture. The CNA involved had recently been hired and had completed competencies related to safe transfers and following care plans. However, the CNA did not adhere to the resident's care plan or the facility's documented transfer protocols, which directly led to the resident's fall and subsequent injury. The incident was documented in the facility's progress notes, incident report, and an x-ray confirmed the fracture. Interviews with staff and review of records confirmed that the resident's care plan and transfer requirements were clearly documented and accessible to staff through the Kardex. The failure to follow these established protocols resulted in actual harm to the resident, as evidenced by the fracture. The deficiency was identified as neglect, defined by the facility as the failure to provide necessary goods and services to avoid physical harm, pain, or emotional distress.