Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect during a transfer, resulting in a fall with injury. The resident, who had multiple diagnoses including congestive heart failure, bilateral lower leg lymphedema, and diabetes, was care planned and assessed as requiring a two-person assist or use of a Hoyer mechanical lift for transfers. Documentation in the resident's care plan and physical therapy reports indicated that extensive two-person assistance was necessary for all transfers, and these requirements were communicated to the interdisciplinary team. Despite these documented needs, a CNA assisted the resident alone during a transfer from a chair to standing, contrary to the care plan and physical therapy recommendations. During this transfer, the resident's knee buckled, resulting in a fall that caused a fracture requiring hospitalization and surgical repair. The CNA was aware of the resident's transfer status but chose to proceed without the required assistance, leading to the incident.