Improper Transfer Results in Resident Fracture Due to Failure to Follow Two-Person Assist Policy
Penalty
Summary
A deficiency occurred when a resident, who had a history of left femur fracture, difficulty walking, atrial fibrillation, and asthma, was not transferred according to the facility's established policy and physician's orders. The resident's care plan and orders specified that transfers required the assistance of two staff members and, as needed, the use of a stand-up lift or walker. Despite these requirements, a CNA attempted to transfer the resident from a shower chair to a wheelchair with only one staff member present and placed towels under the resident's feet to keep them dry. During the transfer, the resident stepped off the towels, slipped, and fell to the floor. The CNA was able to support the resident's upper body and lower them to the ground, but the resident's lower body fell, resulting in significant pain and an inability to move the left leg. Assessment revealed the left lower extremity was bent and externally rotated, and the resident reported severe pain. The resident was subsequently sent to the emergency room, where a left hip/femur fracture was confirmed. Staff interviews and facility documentation confirmed that the CNA did not follow the resident's care plan or the facility's policy, which required two-person assistance for transfers. The incident was further corroborated by statements from other staff and the Director of Nursing, who verified that the transfer was performed improperly with only one staff member. This failure to follow established protocols directly resulted in actual harm to the resident.