Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who had multiple medical conditions including hemiplegia, hemiparesis, muscle weakness, and was dependent on staff for all activities of daily living, was transferred without the required mechanical lift and two-person assistance. The resident's care plan and physician orders specified that transfers must be performed using a mechanical lift with two staff members due to her inability to bear weight and significant physical debility. Despite these clear directives, a CNA manually transferred the resident with the assistance of a family member, rather than using the mechanical lift as ordered. During the manual transfer, the CNA bear-hugged the resident and, while holding her up, a popping sound was heard from the resident's right arm. The resident immediately expressed severe pain, and subsequent assessment and hospital evaluation revealed an anterior shoulder dislocation and a right humeral neck fracture. Interviews with staff and the resident's representative confirmed that the transfer was performed by a single CNA without the mechanical lift, and that the family had previously requested that the lift not be used. The CNA admitted to having transferred the resident manually on prior occasions, despite knowing the care plan and physician orders required the use of a mechanical lift with two staff. Facility policy required strict adherence to physician orders for transfers, including the use of mechanical lifts for non-weight-bearing residents, and mandated that staff not deviate from these orders even if requested by residents or their families. The incident was reported by staff, and it was acknowledged by the DON and other staff members that the CNA's actions were not in compliance with established protocols and orders. The failure to follow the prescribed transfer method directly resulted in a significant injury to the resident.