Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Fracture
Penalty
Summary
Facility A failed to implement the comprehensive, person-centered care plan for one sampled resident, resulting in actual harm. The facility’s policy dated 1/1/2023 required development and implementation of comprehensive care plans with measurable objectives and timeframes to meet residents’ medical, nursing, mental, and psychosocial needs. The quarterly MDS for Resident 112 dated 11/29/2025 documented a BIMS score of 15, indicating little to no cognitive impairment, and noted that certain transfers were not attempted due to medical condition or safety concerns. Active diagnoses included dementia, muscle weakness, congestive heart failure, osteoarthritis, and hypertension. The resident’s care plan, initiated 6/8/2022 and revised 2/7/2024, specified that the resident needed assistance with grooming, bathing, and personal hygiene related to mobility and self-care impairment, and required two people at all times when giving care. Interventions included bathing assistance of two people, a requirement for two people for all care provided, and transfer assistance of two people with a mechanical lift. Despite these documented care plan interventions, on 12/5/2025 Certified Nurse Aide LL transferred the resident without assistance, contrary to the requirement for two-person mechanical lift transfers. Following a transfer to a shower chair, the resident complained of pain to the left shoulder and was noted to have bruising under the left axilla and left arm. An incident report dated 12/7/2025 recorded these findings, and an X-ray showed a fractured left proximal humerus. In interviews, CNA LL confirmed that the resident required a mechanical lift transfer with two people and acknowledged transferring the resident alone. The National Director of Risk Management and the Administrator both confirmed that the care plan documented the need for two-person assistance with a mechanical lift for transfers.
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