Failure to Provide Required Two-Person Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments was not provided the required level of assistance during a transfer. The resident, who had diagnoses including dementia, muscle weakness, abnormal gait, and a history of femur fracture, was care planned to require a mechanical lift with two staff for all transfers. Despite this, a CNA transferred the resident from bed to wheelchair by holding onto the resident's pants and using a gait belt, without the assistance of a second staff member or the mechanical lift as required. The CNA did not consult the assignment sheet at the start of her shift, which would have indicated the resident's transfer needs. Interviews with facility staff, including the DON, RN, LVN, and multiple CNAs, confirmed that the expectation and policy were for the resident to be transferred with a mechanical lift and two staff at all times. Assignment sheets detailing each resident's transfer requirements were available at each nurse's station, and staff were expected to review these at the beginning of each shift. The incident report and hospital records indicated that the resident sustained an acute, slightly displaced fracture of the left greater trochanter as a result of the improper transfer. The resident was subsequently hospitalized and returned to the facility with pain management orders. The investigation found that the CNA involved had not followed established procedures for reviewing assignment sheets or adhering to the resident's care plan. The resident's inability to recall the incident or report pain was consistent with her documented cognitive impairment. Other staff interviews confirmed knowledge of the correct transfer procedures and the location of assignment sheets, but the failure to follow these protocols in this instance led directly to the resident's injury.