Failure to Follow Individualized Transfer Care Plan Results in Resident Injury
Penalty
Summary
Certified medical assistant (CMA) G and certified nursing assistant (CNA) I failed to follow the individualized care plan for a resident who required assistance with transfers using a sit-to-stand mechanical lift and two staff members. Instead, they performed a stand and pivot transfer, deviating from the prescribed method. This decision was made because the resident was reportedly anxious, and the staff believed using the mechanical lift would increase her agitation. The staff did not consult with nursing leadership or the resident's care team before making this change. During the unauthorized transfer, the resident's right leg was positioned next to the CNA's left leg. After the transfer, blood was discovered on the resident's pant leg and the CNA's shoe. Upon assessment by nursing staff, a large laceration was found on the resident's right lower leg, which required emergency medical attention and sutures. The resident was transferred to the emergency department for treatment and later returned to the facility with wound care instructions. The resident involved had a severely impaired cognitive status, as indicated by a Brief Mental Status (BIMS) score of 0, and multiple diagnoses including Alzheimer's disease, dementia, anxiety, iron deficiency anemia, localized edema, chronic peripheral vascular disease, and hypertension. The facility's policy required staff to follow the resident's care plan for safe transfers and to consult nursing leadership if uncertain about transfer methods. Despite this, the staff independently decided to alter the transfer method without proper consultation or documentation.