Failure to Follow Care-Planned Transfer Method Resulting in Unsafe Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was free from accident hazards and that transfers were performed in accordance with the resident’s care plan. The resident had diagnoses including Alzheimer’s disease, chronic kidney disease, and depression, and the care plan in place since July 21, 2025 specified that the resident required a sit‑to‑stand mechanical lift with two staff for all transfers. On the date of the incident, a nurse aide (Employee E3) attempted to transfer the resident from bed to chair without using the prescribed two‑person stand‑up lift and instead stood the resident up from the edge of the bed. When the resident was unable to stand, the aide guided the resident down to the floor mat and then sought assistance from other staff. Interviews and documentation showed that the aide performing the transfer did not verify or follow the resident’s transfer status as outlined in the care plan and available in the Kardex and assignment sheet. Another nurse aide (Employee E4) reported having given shift report and that the aide had access to the Kardex and assignment information, but believed the resident was a stand‑and‑pivot transfer. Review of transfer documentation from several days around the incident revealed inconsistent recording of the resident’s transfer needs, with some entries showing two‑person assist and total dependence, and others documenting one‑person assist, extensive assistance, independence, or not applicable. The Nursing Home Administrator confirmed that the aide did not ensure the transfer method was consistent with the plan of care and that any mechanical lift requires two staff to operate.
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