Failure to Follow Safety Protocols During Bathing and Transfers Resulting in Resident Injuries
Penalty
Summary
Certified nursing assistants (CNAs) failed to follow established safety protocols during resident bathing and transfers, resulting in serious injuries to multiple residents. In two separate incidents, CNAs removed the whirlpool bath chair safety belt before the residents were ready to be transferred, leaving the residents unsecured. In one case, a CNA turned away from a resident after removing the safety belt to retrieve nail clippers, and the resident fell forward out of the bath chair, sustaining a pelvic fracture. In another case, a CNA removed the safety belt to dry a resident and turned away, leading to the resident falling out of the chair and suffering multiple fractures, including to the spine, pelvis, and tibia. Both residents required hospitalization for their injuries. Additionally, a CNA failed to follow the care plan for a resident requiring transfer with a mechanical total lift and assistance from two staff members. Instead, the CNA transferred the resident alone and used the incorrect lift device, contrary to the resident's care plan and facility policy. This resulted in the resident sustaining an acute fracture of the proximal tibia in her lower left leg. The injury was discovered later when a bruise was noted, and subsequent assessment and imaging confirmed the fracture. The resident was under hospice care at the time of the incident. Interviews and observations confirmed that staff were aware of the facility's policies requiring the use of safety belts during bathing and the need for two staff members during mechanical lift transfers. Documentation showed that the involved CNAs had previously received training on these procedures. Despite this, the protocols were not followed, directly leading to the residents' injuries during routine care activities.