Failure to Ensure Safe Transfer Practices and Accident Prevention
Penalty
Summary
The facility failed to ensure safe transfer practices for two residents identified as being at risk for falls and requiring assistance. One resident, with a history of falls, decreased muscular coordination, and the use of assistive devices, was transferred by a CNA without the use of a gait belt, contrary to facility policy. The CNA lifted the resident by the waistband of her pants during transfers from a recliner to a wheelchair and from the wheelchair to the toilet. Another CNA confirmed that a gait belt should be used for all transfers involving this resident. A second resident, admitted with multiple diagnoses including osteoarthritis, osteoporosis, and Alzheimer's disease, had a history of falls and was care planned for sensor alarms and assistance with transfers. During observed transfers, two CNAs used a gait belt but lifted the resident, who was unable to bear weight, by the gait belt and then by holding under her arms and legs. The resident's bed alarm did not sound, and no wheelchair alarm was applied. Documentation showed the resident had experienced skin tears and falls during previous transfers. Staff interviews indicated that the resident was not bearing weight and should have been re-evaluated by nursing and therapy. Facility policy required safe handling and regular review of mobility needs, which was not followed in these instances.