Failure to Ensure Safe Resident Transfers Resulting in Multiple Fractures
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident without using a gait belt and without the required assistance, resulting in the resident sustaining fractures to both lower extremities on two separate occasions. The resident, who had multiple sclerosis, lack of coordination, and was dependent on staff for all transfers, was transferred from a shower chair to the bed by a single CNA, despite care requirements for two-person assistance and the use of a mechanical lift. The care plan did not contain transfer instructions prior to the incidents, and the CNA did not receive training before or after the first incident. The resident reported that during both transfers, her legs became caught between the shower chair and the bed, resulting in pain and audible popping sounds, which were later confirmed as fractures by x-ray. The resident was not immediately sent to the hospital after the first fracture and experienced unmanaged pain until transfer to the hospital. The CNA involved admitted to performing the transfers alone and without a gait belt, and also stated that no training was provided after the first incident. Other staff interviews confirmed a lack of training and monitoring related to safe transfer techniques. Additionally, observations of another resident's transfer revealed improper use of a mechanical lift, including failure to lock the bed and wheelchair, use of an incorrectly sized sling, and mismatched sling loops, contrary to manufacturer instructions. Staff involved in these transfers expressed uncertainty about proper procedures and equipment sizing. Facility policies required review of care plans and use of two trained staff for mechanical lifts, but these were not consistently followed, contributing to the deficiencies identified.
Removal Plan
- In-service nursing staff on where to find the resident's care plan to determine how to care for the resident. The care plan is found on the electronic screen system on each hall and general area. The resident transfer section on the care plan will tell the nursing team member how the resident is to be transferred.
- Educate nursing team members on the process of transferring residents by using their proper body mechanics or using a transfer device for the safety of both residents and staff.
- Complete a skills check-off tool on the nursing team members so they can demonstrate the process of transferring residents by using their proper body mechanics or using a transfer device for the safety of both resident and staff.
- Any nurse not present or in-serviced will not be allowed to assume their duties until in-serviced. ADM will ensure these team members are removed from the time clock and PCC access removed, this will be monitored until 100% complete or the team members are terminated.
- Ongoing in-service will be completed by the DON, ADON D, and ADON E until all staff, weekend, and PRN are completed.
- Bring in a Licensed Physical Therapist to educate, complete a skills check-off list, and post-test on transferring a resident.
- PT to educate, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices with DON, ADON D, and ADON E. After they completed and passed their education, PT observed DON and ADONs educate, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices with 3 CNAs.
- Only DON, ADONs, and PT will be able to in-service, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices.
- A resident can only be transferred using a Hoyer lift with a licensed nurse present. This practice will continue until the IDT Team decides the CNAs are able to complete this transfer without supervision.
- Monitor resident transfers by CNA every shift by the DON and ADONs. Administrator will monitor this process daily.
- Test nursing staff on where to find the resident's care plan every shift by the DON and ADONs. ADM will monitor this process daily.
- Hold Ad Hoc QA meeting to discuss causes, in-services and review interventions.
- Any negative findings in the monitoring and/or auditing system will be reviewed and addressed by the QAPI committee for a potential systemic change.
- Ensure that all mechanical transfer train-the-trainer sessions, center random skill checks, and instances where transferring is found to be done incorrectly, will be supervised, monitored, and approved by a licensed physical therapist.