The incident at Reginald P White Nursing Facility occurred when CNA #2 told CNA #1 that transfer protocols had recently changed to require only two staff members. That was false.
CNA #1 revealed during a phone interview that she was asked by CNA #2 to assist in transferring the resident into her transfer chair. Following the transfer with the mechanical lift, the resident was seated upright in the chair when it flipped backward.
"The resident was normally transferred with three CNAs and a nurse present," CNA #1 told investigators. But CNA #2 had told her the protocol had recently been changed to only two CNAs.
The facility's Director of Nursing confirmed that staff failed to provide necessary care and supervision to ensure the resident's safety during the transfer. She stated that two CNAs attempted the transfer using a mechanical lift without obtaining the additional assistance required to safely complete the procedure.
The resident's condition required more staff support due to physical limitations and risk for instability. Performing the transfer with only two CNAs did not meet the resident's needs and placed her at risk for injury.
"The incident may have been prevented if staff had followed established facility expectations for safe transfers," the Director of Nursing stated. She emphasized that it is the facility's responsibility to ensure that staff provide necessary care and services to prevent neglect and protect resident safety.
The Administrator confirmed that despite adequate staffing and clear instructions requiring a four-person assist for this resident's transfers, the two CNAs failed to obtain the additional assistance required to safely complete the transfer.
This failure to provide necessary care and services placed the resident at risk for injury and constituted neglect, as staff did not ensure the resident's safety during the transfer. The facility maintained written policies addressing resident safety during transfers, proper use of mechanical lifts and transport chairs, and adherence to physician orders and care plans.
All staff had been trained, and competencies validated on these procedures.
The facility immediately suspended and later terminated both CNAs for failing to follow safety policies. Management initiated in-services for all nursing staff on proper mechanical lift use and resident supervision.
Emergency Quality Assurance and Performance Improvement meetings were convened on September 2nd and September 5th to review the incident, reinforce policies, and prevent recurrence.
The Administrator confirmed that the facility reported the incident to the State Agency and the Attorney General's Office within the required five-day timeframe.
State inspectors determined the deficiency to be past non-compliance, corrected as of September 5th, prior to their first entrance on October 20th. They validated through interview and record review that all corrective actions had been implemented and the facility was in compliance before their arrival.
The violation involved minimal harm or potential for actual harm to few residents. But the incident highlighted how individual staff decisions to ignore established safety protocols can put vulnerable residents at immediate risk during routine care procedures.
CNA #2's false claim about changed protocols led to a dangerous situation that could have resulted in serious injury. The resident's physical limitations and instability made the four-person requirement essential for safe transfers.
The facility's swift response included terminating both employees involved, regardless of whether they initiated the protocol violation or simply followed incorrect instructions from a colleague. Management treated both CNAs as equally responsible for the safety breach.
The mechanical lift transfer that should have involved four trained staff members became a two-person procedure that ended with the resident's chair flipping backward. The incident demonstrated how quickly routine care can become dangerous when established safety measures are abandoned.
Staff training and competency validation had been completed for proper transfer procedures. Written policies clearly outlined requirements for mechanical lift use and resident supervision during transfers. The facility had adequate staffing available to meet the four-person requirement.
Despite these safeguards, two CNAs chose to proceed with an unsafe transfer method. Their decision placed a physically limited resident at risk during what should have been a routine procedure with multiple safety checks built into the process.
The emergency quality assurance meetings following the incident focused on reinforcing existing policies rather than creating new ones. Management determined that the established procedures were adequate to prevent such incidents when followed correctly.
The facility's immediate reporting to both the State Agency and Attorney General's Office within the required timeframe demonstrated compliance with notification requirements. Their quick implementation of corrective actions resulted in the deficiency being classified as past non-compliance before state inspectors arrived.
The resident's transfer chair flipping backward represented a preventable incident that occurred despite proper policies, adequate staffing, and completed staff training. Two employees' decision to ignore established safety protocols created unnecessary risk during routine care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Reginald P White Nursing Facility from 2025-10-22 including all violations, facility responses, and corrective action plans.
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