Resident Injury During Unsafe Transfer
Penalty
Summary
The facility staff failed to operate equipment safely, resulting in a resident sustaining injuries during a transfer. The incident involved a Certified Nursing Assistant (CNA) who was transferring the resident from the bed to a wheelchair. During the transfer, the CNA did not position the wheelchair correctly and let go of the resident momentarily, causing the resident to hit her arm on the wheelchair's armrest. This incident was not immediately reported by the CNA, and the injuries were later discovered by a family member. The resident involved in the incident required substantial to maximal assistance for chair or bed-to-chair transfers, as indicated in their care plan. The care plan also highlighted the resident's risk related to mobility and included interventions such as encouraging the resident to ask for assistance when attempting to transfer. Despite these precautions, the CNA did not follow the correct procedure for transferring the resident, which contributed to the accident. The facility's policies on safety and supervision of residents emphasize the importance of making the environment as free from accident hazards as possible. However, the CNA failed to report the incident to the nurse, which was against the facility's policy on accidents and incidents. The Director of Nursing confirmed that the CNA was reprimanded for not reporting the incident, and the incident was later documented in the facility's incident log.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. **IMMEDIATE CORRECTIVE ACTION:** Staff A was counseled by Director of Nursing and competency was completed regarding safe patient transfers on Resident #1 did not have any negative outcomes related to the alleged deficient practice. Nursing staff was in-serviced by the Director of with competency completed on safe resident transfers on and. **IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED:** Any resident requiring assistance with transfers have the potential to be affected by the alleged deficient practice. A facility wide audit was conducted on to identify any residents needing assistance with transfer to ensure that staff are aware and that facility policy is being followed. **SYSTEMATIC CHANGES:** The Assistant Director of Nursing conducted ongoing in-services with nursing staff regarding safe transfers and proper notification of resident's representative and physician. Nursing staff was in-serviced by the Director of with competency completed on safe resident transfers on and. **MONITORING:** The Director of Nursing/Designee will conduct weekly random observation and competency checks with nursing staff x four weeks, then monthly random observation and competency checks x 3 months to ensure nursing staff are transferring residents safely according to facility policy and procedures. The Director of Nursing/Designee will report findings to the Quality Assurance committee monthly for 3 months to ensure substantial compliance is achieved and maintained.