Failure to Follow Transfer Protocols and Ensure Agency Staff Training
Penalty
Summary
A deficiency occurred when a resident who required an EZ stand mechanical lift with the assistance of two staff for transfers was transferred by a single agency CNA, contrary to the resident's care plan. The CNA was aware from shift report and the care plan that two staff were needed for all transfers due to the resident's weakness, but attempted to transfer the resident alone after being unable to find another staff member. During the transfer, the resident's leg gave out, resulting in the resident slipping from the lift and being lowered to the floor, which led to a non-displaced left clavicle fracture. The resident, who had a history of left below-the-knee amputation, type 2 diabetes, hypertensive heart disease with CHF, and was cognitively intact, requested to be sent to the emergency room due to pain and decreased range of motion following the incident. However, the agency RN on duty did not transfer the resident immediately because the RN did not know how to complete the necessary paperwork. The resident was eventually sent to the ER approximately two hours later when the night shift nurse arrived. The facility's policies required that staff follow the resident's care plan for transfer assistance and that training occur after transfer-related incidents. Despite identifying the deficient practices, the facility did not ensure that all agency staff who had worked since the incident received or acknowledged the required education regarding transfer procedures and care plan adherence. The process for ensuring agency staff received and signed off on education was not effective, as most agency staff did not know to check the clipboard where such information was posted.