Improper Transfer Results in Resident Injury Due to Failure to Follow Care Plan
Penalty
Summary
A deficiency occurred when a resident who required moderate assistance with transfers, including the use of a mechanical lift and two-person assistance as specified in his care plan, was improperly transferred by a CNA. The CNA manually transferred the resident multiple times without the mechanical lift, using either a gait belt or lifting the resident under his arms, despite the resident's care plan and facility policy requiring mechanical lift use. The improper transfer resulted in the resident sustaining extensive bruising across the chest and multiple rib fractures, as confirmed by medical assessment and imaging. The resident, who had a history of dementia, mobility issues, and previous sternal fracture, was found with significant bruising and a skin tear after the transfers. Interviews with the resident, his family member, and facility staff revealed that the CNA did not follow the prescribed transfer method and that similar improper transfers may have occurred previously. The resident and his family had reported discomfort and pain during these manual transfers, and the family member witnessed the CNA lifting the resident under his arms instead of using the mechanical lift. Facility records and staff interviews confirmed that the resident's care plan had been updated months prior to require mechanical lift transfers with two staff members due to his decline. The CNA involved admitted to transferring the resident without the mechanical lift on the day of the incident, citing the unavailability of the lift pad and the resident's recent decline. Other staff and the DON confirmed that the resident should have been transferred only with a mechanical lift and two-person assistance, and that failure to follow these procedures could result in injury.