Failure to Implement Consistent Transfer Instructions Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure safe transfer practices and implement clear, consistent transfer instructions for a resident reviewed for falls. Staff attempted to transfer the resident using a sit-to-stand lift, despite recent therapy recommendations indicating the need for a full mechanical lift (Hoyer) due to the resident's instability and inability to safely bear weight. During the transfer, the resident's foot slipped from the lift platform, and staff were unable to safely reposition the foot, resulting in the resident being lowered to the floor. The transfer was then completed using a full mechanical lift. The resident subsequently complained of pain, and an assessment revealed swelling and a femur fracture, requiring hospitalization and surgical intervention. Review of the resident's care plan revealed conflicting transfer instructions, with both sit-to-stand and full mechanical lift interventions listed simultaneously. The clinical record did not contain evidence that nursing staff were notified of the change in transfer status prior to the incident. The resident's functional assessment indicated a need for substantial to total assistance with transfers, and the care plan had not been appropriately updated to reflect the therapy recommendations. The administrator confirmed that the care plan continued to list both transfer methods and had not been edited to reflect the change.