Failure to Safely Transfer Resident
Penalty
Summary
The facility failed to safely transfer a resident who required assistance from staff for transfers, leading to a deficiency. The resident, who had flaccid hemiplegia affecting his left dominant side, was dependent on staff for chair/bed-to-chair transfers. Physician's orders specified that the resident be transferred with the assistance of two staff members. However, an incident occurred where the resident was found on the floor in his room after being transferred by only one staff member, Nurse Aide 2. The resident was not injured and was assisted back to bed using a mechanical lift. The incident was further clarified through a witness statement from Nurse Aide 2, who attempted to transfer the resident alone when she found him at the tip of his chair about to fall. She tried to put him in bed, but his pants got stuck, and she was unable to unhook him, leading her to lower him to the ground. An interview with the resident confirmed that he sometimes was transferred with one staff member and sometimes with two, and he expressed a preference for two staff members for comfort. The Director of Nursing's interview revealed that the resident was not transferred according to the physician's orders because Nurse Aide 2 felt the resident was at risk of falling from his chair.
Plan Of Correction
1. The facility cannot retroactively address the incident. Resident 7 was not injured. 2. Residents reviewed to confirm their transfer status. The Interdisciplinary team will review changes in transfer status during morning clinical meeting to make sure the information is updated in the care plan. 3. The Director of Nursing or designee will educate the Nursing staff including agency will be educated on resident transfer status and asking for assistance if needed. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks then monthly for two months on residents transfers to determine if the transfer status is being followed per order. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.