Failure to Follow Transfer Protocols Results in Resident Injuries
Penalty
Summary
The facility failed to ensure that appropriate transfer techniques were implemented for two residents, resulting in injuries. One resident, a female admitted for physical and occupational therapy following a previous femur fracture, was assessed as requiring limited assistance for transfers, with therapy recommendations including the use of a front-wheeled walker, wheelchair, gait belt, and verbal cues. During an assisted transfer from the bathroom to the bed, the CNA did not use a gait belt as required by the resident's care plan. While the CNA was pulling down the bedding, the resident let go of her walker to point at the bed control and fell backward, sustaining a hand laceration and a new acute fracture to her distal femur. The CNA admitted to not checking the care plan and not realizing a gait belt was required for the transfer. Another resident, a female with gastroparesis and dependent for care, was to be transferred with a hoyer lift to the toilet and a slide board only for bed-to-wheelchair transfers. Over a weekend, staff used a slide board transfer to the toilet instead of the required hoyer lift, and when the process took too long, staff reportedly picked the resident up and placed her on the toilet, resulting in bruising on her inner upper arms. Multiple interviews confirmed that the resident's care plan specified a hoyer lift for toilet transfers, and staff were either unaware of or did not follow these instructions. The resident and several staff members reported the improper transfer and resulting bruising. In both cases, the deficiencies were due to staff not following the residents' care plans and not using the required assistive devices or transfer techniques. Staff either did not check the care plans or made assumptions about the residents' transfer status, leading to improper handling and injury. The incidents were witnessed, reported, and confirmed through interviews, observations, and record reviews.
Plan Of Correction
1. One of the residents had discharged at the time of the survey. The care plans of the other affected resident were reviewed and updated by the Interdisciplinary Team (IDT). Updated level of assistance and transfer status were shared with clinical teams by leadership to ensure understanding and compliance. 2. All residents have the potential to be affected. 3. Clinical Oversight Committee will audit care plans to ensure clear direction and appropriate levels of assistance. Refreshed education was provided to clinical staff on where to locate care plan information on EMR devices, and they were reminded to always carry these devices to be ready to verify care plans and assistance levels. Policies were reviewed, and no necessary updates were identified. 4. Routine audits of five care plans are conducted weekly at Clinical Oversight meetings for clarity of assistance levels. Additionally, five weekly audits are performed on transfers to ensure the transfer aligns with care plans. There are also five weekly audits of staff demonstrating where to locate care plan information on devices, and audits to ensure devices are on staff members at all times to guarantee they are always ready to access the care plan. 5. The Executive Director is responsible for compliance.