Failure to Provide Required Two-Person Assistance During Transfer Results in Resident Fractures
Penalty
Summary
A resident with Parkinson's disease, who was cognitively intact and required the assistance of two staff members with a gait belt for transfers, sustained significant fractures to the left tibia and fibula. The resident's care plan and transfer evaluation clearly documented the need for two-person assistance during transfers. However, staff interviews and documentation revealed that the resident was routinely transferred by a single nursing assistant using a stand pivot transfer (SPT) technique, contrary to the care plan requirements. Multiple staff members, including nursing assistants and the Director of Rehabilitation, confirmed that the resident was often transferred independently and that the resident had difficulty lifting their foot during transfers, which led to twisting of the leg. The resident reported hearing a pop and falling backward during a transfer when only one staff member was present. Staff schedules confirmed that the staff involved were on duty during the relevant period, and there was no evidence provided by the facility to show that two-person assistance was consistently provided as required. The investigation determined that the resident's injuries were consistent with improper or inadequate assistance during a transfer, specifically a twisting injury that can occur when a resident is not properly supported. The facility failed to ensure that the resident received adequate supervision and assistance during transfers, as outlined in the care plan and transfer evaluation, which likely contributed to the resident's fractures.