Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident, who required a two-person assist for transfers using a mechanical lift as specified in their care plan, was transferred from a chair to bed by a single Certified Nurse Aide (CNA) without assistance. The CNA admitted to performing the transfer alone, despite being aware of the resident's care plan and having received training and signed acknowledgment regarding the requirement for two-person assistance during mechanical lift transfers. Facility policies and the resident's Kardex clearly documented the need for two staff members for such transfers. Following the unassisted transfer, the resident was later found with flaccidity and deformity to the right hip and leg. Assessment by nursing staff and subsequent hospital evaluation revealed a periprosthetic right spiral hip fracture with an unstable prosthesis, necessitating surgical intervention. The resident was unable to communicate due to severe dementia, and the injury was identified during routine morning care by another CNA, who promptly reported the abnormality to nursing staff. Interviews with facility staff confirmed that there were no staffing shortages at the time of the incident, and other CNAs were available to assist. The CNA responsible for the transfer acknowledged knowledge of the care plan requirements but chose to proceed alone. The facility's investigation and staff interviews corroborated that the CNA had received appropriate orientation and training regarding safe transfer procedures and the necessity of following the resident's individualized care plan.