Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Injury
Penalty
Summary
The facility failed to follow a resident’s care plan requiring use of a mechanical lift with two staff for transfers, instead transferring the resident with two staff and a gait belt. The resident had dementia with severely impaired cognition, a history of an intertrochanteric left femur fracture, muscle weakness, behaviors including wandering and rejection of care, and required increasing assistance with ADLs over time. Earlier assessments documented moderate assistance with transfers, but a later MDS showed the resident required total assistance with bed mobility, toileting hygiene, and transfers, and was at risk for pressure ulcers with one unhealed, unstageable pressure injury not present on admission. The care plan dated 09/25/24 specifically identified the need for total assistance of two staff with a mechanical lift for transfers. On 11/04/25, staff identified a large bruise on the resident’s left chest under the arm, measuring 22.5 cm by 9.5 cm, purple with red areas, and painful to touch; the resident could not state how the bruise occurred. Subsequent facility risk management documentation dated 11/17/25 revealed staff had been transferring the resident with two staff and a gait belt, contrary to the care-planned requirement for a mechanical lift. Staff interviews confirmed that CNAs and CMAs were expected to follow the care plan and use the EMR Kardex to determine required interventions, and that nursing was responsible for coordinating resident care. Despite these expectations and policies, the resident’s transfer was performed without the ordered mechanical lift, resulting in an injury.
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