Failure to Prevent Accident Due to Improper Transfer
Penalty
Summary
The facility failed to prevent an accident involving a resident who required a mechanical lift and two-person assistance for transfers due to severe cognitive impairment, left hemiplegia, and other significant medical conditions. According to the care plan and physician orders, the resident was to be transferred using a Sara lift with the help of two staff members. However, a certified nurse aide (CNA) who was new to the facility attempted to transfer the resident alone using a stand-pivot method after being informed by a registered nurse (RN) that the resident was a one-person assist and able to stand and pivot. The CNA was unaware of the resident's actual transfer requirements and did not review the care plan or consult with nursing staff prior to the transfer. During the transfer, the resident fell, resulting in a 7 cm skin tear on the left lower leg with active bleeding. The incident report identified gait imbalance as a predisposing factor and noted that the CNA was not aware that a mechanical lift and additional assistance were required. The resident's care plan, which documented the need for a Sara lift and two-person assistance, was not accessed or referenced by the CNA prior to the transfer. The CNA also reported that the resident refused the mechanical lift and requested a stand-pivot transfer, which was performed without proper authorization or support. Interviews with staff revealed gaps in communication and access to care plan information. The director of nursing (DON) stated that transfer statuses and mechanical lift requirements were documented in care plans, but CNAs did not have full access to these documents and were expected to ask nurses for clarification. The DON also indicated that the CNA did not seek guidance before performing the transfer. The incident highlighted a breakdown in communication regarding the resident's transfer needs and a lack of adherence to established protocols for safe resident handling.