Failure to Follow Two-Person Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident with severe cognitive impairment, vascular dementia, a history of stroke, and osteoarthritis. The resident had a physician's order and care plan requiring a two-person assist for all transfers due to their medical condition and mobility limitations. Despite this, the CNA transferred the resident alone from a wheelchair to a bed, using a 'bear hug' technique, which was not in accordance with the established care plan or facility policy. Following the transfer, the resident was found to have a bruise, swelling, and pain in the left upper arm. An X-ray confirmed an acute fracture of the proximal humerus. The CNA admitted during interviews that they performed the transfer alone and did not check the care plan or seek assistance, stating they believed the resident had always required only a one-person assist. The CNA also reported that they did not notice any injury or discomfort during or immediately after the transfer. Facility investigation determined that the CNA's failure to follow the two-person assist order directly contributed to the resident's injury. The incident was identified through review of medical records, staff interviews, and the facility's accident/incident report. The resident's medical history, including frailty and easy bruising, was noted as a factor that increased the risk of injury during improper transfers.