Failure to Follow Safe Transfer Protocols for Dependent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan and facility policy regarding safe resident transfers. The CNA provided a one-person manual lift by placing his arms under the resident's armpits to transfer her from bed to wheelchair, rather than using a mechanical lift with two staff as required. The resident involved was a female with severe cognitive impairment, dependent on staff for all activities of daily living except eating, and required two-person assistance with transfers due to impaired balance and diagnoses including dementia and multiple sclerosis. The care plan specifically indicated the use of a mechanical lift with two staff for all transfers. During the incident, the CNA did not use a gait belt and was unfamiliar with the resident's care needs, admitting he should have checked the care plan or asked for guidance. Interviews with facility staff, including the physical therapy assistant and the director of nursing, confirmed that the proper procedure for this resident was a mechanical lift with two staff, and that lifting under the arms is prohibited due to risk of injury. Facility policy also mandates the use of appropriate lifting devices and techniques, and manual lifting is to be eliminated when feasible. The failure to follow these protocols resulted in a deficiency related to accident hazards and inadequate supervision.