Failure to Follow Two-Person Transfer Care Plan Resulting in Resident Injury
Penalty
Summary
The deficiency involves a failure to ensure a resident was transferred according to the care plan, resulting in injury. A resident with intact cognition, muscular dystrophy, unsteadiness on her feet, and decreased mobility had a care plan dated 11/24/25 indicating she required extensive assistance of two staff members for transfers. On 1/15/26 at around 4:00 p.m., a CNA, who knew the resident required two-person assistance, attempted to transfer the resident alone. During this transfer, the resident’s left leg struck her wheelchair, causing two skin tears, and she later experienced increased pain in her left knee, for which an x-ray was obtained on 1/19/26. The CNA reported that she had previously transferred the resident alone without problems and described grabbing the resident under the armpits, lifting her from the wheelchair, and turning to place her on the bed. She realized the bed was not in a low position and could not lift the resident high enough, so she turned back to place the resident in the wheelchair. As the resident was set down, she began to slide out of the wheelchair and was lowered to the floor, during which her leg hit the wheelchair and the skin tears occurred. Other CNAs interviewed knew where to find resident care and transfer information. The facility’s CNA job description and care plan policy required CNAs to be knowledgeable of and follow individual care plans, and to provide care that maintains skin integrity and safeguards residents’ health, safety, and welfare.
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