Failure to Follow Transfer Protocols Results in Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a stand-up lift instead of the Hoyer lift as required by the resident's care plan and physician's order. The resident, who had a history of intervertebral disc stenosis, neuropathy, morbid obesity, osteoarthritis of the knee, and significant lower extremity edema, was assessed as high risk for falls and unable to bear weight safely. Despite clear documentation and staff awareness that the resident required a Hoyer lift and two-person assistance for transfers, the CNA proceeded alone with the stand-up lift. During the transfer from a shower chair to bed, the resident slid out of the stand-up lift and fell to the floor. The resident reported discomfort and pain, particularly in her shoulders, which had previously been replaced. She stated that the stand-up lift caused pressure and discomfort, and that she had warned the CNA she was falling. The incident was witnessed by an ultrasound technician present in the room. The resident was later transported to the emergency department for evaluation due to shoulder pain, but imaging showed no acute fracture or dislocation. Interviews with staff, including other CNAs, the Director of Staff Development, and the Director of Nursing, confirmed that the resident's care plan and physician's order specified the use of a Hoyer lift with two staff members for all transfers. The CNA involved acknowledged awareness of these requirements but stated she used the stand-up lift at the resident's request and performed the transfer alone. Facility policy also required two staff for mechanical lift transfers. The failure to follow established protocols and orders resulted in the resident's fall and subsequent discomfort.