Failure to Follow Transfer Protocols for Resident
Penalty
Summary
The facility failed to adhere to the prescribed transfer status for a resident, leading to a deficiency. Resident 68, who was cognitively intact and required two-person assistance for transfers, was involved in an incident where only one nurse aide attempted to transfer the resident from the bed to a wheelchair. During this transfer, the resident became weak and was slowly lowered to a sitting position on the floor. The resident, who had diagnoses of acute respiratory failure and muscle weakness, was assessed after the incident and found to have no injuries or complaints of pain. The Nursing Home Administrator confirmed that the transfer should have been conducted by two staff members, as per the resident's care requirements.
Plan Of Correction
1. Incident report/Investigation completed at time of incident. Immediate intervention, education and Relias training given to direct staff involved. 2. Care plan and Kardexs audited on residents for transfer statuses. 3. The Director Of Nursing/Designee will educate nursing staff on- Lifting and moving residents, Transfer/Mobility evaluation Low Lift, and Low Lift program and document education. Annual education to continue per facility protocol on transferring residents. 4. Audits/Staff interviews will be completed on 3 random staff members to ensure staff knowledge of where to obtain resident transfer status information 3x weekly x 2 weeks, then weekly x 4. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Improvement Committee for additional oversight.