Failure to Follow Two-Person Transfer Care Plan
Penalty
Summary
A deficiency occurred when a resident’s care plan for transfer assistance was not followed, resulting in a failed transfer. The resident had a history of stroke within the past year with left-sided involvement, including a flaccid left arm that the resident was unable to move. The resident’s care plan, initiated for a deficit in functional mobility, specified that two staff members were required for all transfers. On 2/10/26, documentation showed that a CNA attempted to transfer the resident from a wheelchair to the bed without a second staff member, contrary to the care plan. During this one-person transfer, the transfer failed and the CNA lowered the resident to the floor. The charge nurse assessed the resident and documented no visible injuries. In the facility’s investigation and in the CNA’s written statement, the CNA acknowledged not following the care plan requiring two staff for transfers, and the Administrator confirmed in an interview that the care plan was not followed.
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