Failure to Follow Two-Person Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including dementia with agitation, Alzheimer's Disease, anxiety, and weakness, and was dependent on staff for transfers, was not assisted by two staff members during a transfer as required by the care plan. The care plan specified that the resident needed a two-person assist for transfers due to functional mobility deficits and a history of being resistive to care. Despite these directives, a nurse aide attempted to transfer the resident alone, without the assistance of a second staff member. During the solo transfer attempt, the resident became agitated and combative, which resulted in the resident hitting their left lower leg on the wheelchair and sustaining a laceration. The injury required medical attention, including transfer to the emergency department and the placement of sixteen sutures. Facility documentation and interviews confirmed that the care plan was not followed, and the transfer was conducted by only one staff member, contrary to established protocols.