Failure to Follow Two-Person Transfer Protocol Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a nurse aide failed to follow the care plan for a resident with severe cognitive impairment and multiple medical conditions, including atrial fibrillation, a history of stroke, and hypertension. The resident required two-person assistance for transfers due to confusion, musculoskeletal impairment, and a history of falls. Despite this, the nurse aide transferred the resident alone from bed to wheelchair, which was not in accordance with the resident's care plan interventions. During the transfer, the bed alarm was triggered, and the nurse aide turned her back to silence it, leaving the resident unattended. As a result, the resident fell forward out of the wheelchair and sustained a large hematoma and a bleeding forehead laceration. The resident was found barefoot, without appropriate footwear or non-skid socks, and was lying face down on the floor. Emergency services were contacted, and the resident was transported to the hospital for evaluation and treatment. Hospital records confirmed that the resident suffered multiple subdural hematomas, a subarachnoid hemorrhage, and a significant forehead laceration, requiring admission to the Progressive Care Unit for several days. Facility documentation and staff interviews substantiated that the nurse aide did not follow the required two-person transfer protocol, directly resulting in the resident's injuries and hospitalization.