Failure to Follow Safe Transfer Procedures for Dependent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan and facility policy for transferring a resident who required extensive assistance due to general weakness, limited mobility, morbid obesity, and muscle conditions. The resident's care plan specified that transfers should be performed using a mechanical lift with the assistance of two staff members. However, on the date in question, the CNA was observed transferring the resident alone, without the use of a mechanical lift, by lifting her under the armpits from the bed to a wheelchair. The CNA admitted to not following the care plan or facility policy, stating he was in a rush to get the resident to therapy and that other staff were occupied at the time. The resident, who had intact cognition and required substantial assistance with activities of daily living, confirmed that transfers were usually performed with two staff and a mechanical lift, and reported no injury during the incident. The Director of Nursing (DON) was unaware of the incident until informed and confirmed that the facility policy required two staff and a mechanical lift for non-weight-bearing residents. The facility's policy also stated that two or more assistants must be used for all mechanical lift transfers.