F0656

D

Failure to Follow Transfer Care Plans Resulting in Resident Injuries

Essexville, Michigan Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure staff followed comprehensive care plans for safe transfers for two residents, resulting in injuries. One resident, an 88-year-old with vascular dementia with behaviors, stroke with right-sided hemiplegia and weakness, heart disease, cognitive impairment, and requiring assistance with all ADLs, had a care plan indicating a two-person assist for all transfers. Despite this, on the early morning of 12/27/25, a CNA attempted to transfer the resident from a wheelchair to bed alone. During the transfer, the resident began screaming, was immediately seated on the bed, and later complained of right knee pain with bruising and swelling. An x-ray on the same date showed a non-displaced fracture of the right fibula.

The same resident’s care plan, dated 12/18/25, clearly documented the need for a two-person assist for transfers. The facility’s accident/incident report for 12/27/25 also noted that the resident’s leg brace became caught on the wheelchair, preventing her from turning and contributing to the injury. The CNA involved acknowledged in the facility’s investigation that she did not follow the resident’s care plan and transferred the resident by herself. At the time of surveyor observation and interview in late January, the resident was in bed, denied pain, and was unable to recall the incident due to cognitive impairment.

A second resident, a 75-year-old who was non-ambulatory, bedbound, required total assistance with all ADLs, and had diagnoses including Alzheimer’s disease, dementia with severe mood disturbance, anxiety, weakness, contractures of the elbows, knees, and left hand, and failure to thrive, also had a care plan requiring use of a mechanical lift with two-person assist for all transfers. Manufacturer guidelines for the lift specified that conditions such as contractures may dictate the need for a two-person transfer. On 12/25/25, a CNA transferred this resident from wheelchair to bed using the mechanical lift with only one staff member assisting, then left the room with the lift and returned to find the resident on the floor with a laceration above the left eyebrow. The CNA then lifted the resident back to bed and notified the nurse. Hospital evaluation, including CT and imaging, showed no significant intracranial hemorrhage and no active findings on chest and pelvic x-rays. The resident’s death certificate later listed Alzheimer’s disease as the cause of death and the manner of death as natural.