Improper Transfer Leading to Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dependent for transfers, and requiring a mechanical lift with two-person assistance was improperly transferred by a single Certified Nursing Assistant (CNA). The CNA used a mechanical lift to move the resident from bed to a reclining chair without the required assistance of a second staff member, as specified in the resident's care plan and facility policy. After placing the resident in the chair, the CNA attempted to adjust the chairback while standing behind the chair. During this process, the resident fell forward out of the chair onto the floor. As a result of the fall, the resident sustained a skin tear to the right lower extremity, bilateral shoulder pain, and a hematoma with an abrasion to the left forehead. The resident was subsequently transported to the hospital for evaluation and treatment. The incident was confirmed through staff interviews, record review, and facility documentation, which indicated that the CNA did not follow the prescribed care plan or facility procedures for safe transfers, constituting neglect as defined by facility policy.