Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A resident who required total assistance with all activities of daily living, including transfers using a mechanical lift with two-person assistance, experienced a fall resulting in significant injuries. The resident's care plan, as documented in the Kardex and Minimum Data Set (MDS), specified the need for two staff members to assist with all transfers due to the resident's high risk for falls and significant cognitive impairment. Despite these documented requirements, a Certified Nursing Assistant (CNA) provided care and attempted a transfer using the mechanical lift without a second staff member present. This action was contrary to the resident's assessed needs and the facility's established protocols. As a result of the CNA's failure to follow the care plan, the resident fell from the mechanical lift, landed on the floor, and sustained a traumatic brain injury, multiple areas of bleeding in the brain, an upper neck fracture, and facial fractures. Facility records and staff interviews confirmed that the CNA did not review or adhere to the Kardex instructions, which were designed to ensure resident safety and prevent such incidents. The incident placed not only the affected resident but also other residents requiring similar assistance at risk for harm.