Failure to Use Proper Transfer Device Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of left knee replacement, mobility issues, and recent fractures was not transferred using the appropriate assistive device as required by her care plan and therapy recommendations. The resident was assessed as dependent for transfers and required a sit-to-stand device for safe movement. However, on the day of the incident, a CNA assisted the resident to the bathroom using only a gait belt and one-person assist, rather than the prescribed sit-to-stand device. During this transfer, the resident's leg gave out, and she was lowered to the ground, resulting in pain and subsequent diagnosis of a left knee periprosthetic fracture of the tibial component. Interviews with facility staff confirmed that the resident was supposed to be transferred with a sit-to-stand device, and the improper transfer method directly led to the injury. The facility's policy requires that residents be handled and transferred safely according to individualized assessments, but this protocol was not followed in this instance. Documentation in the resident's medical record and care plan indicated her high risk for falls and need for substantial assistance, yet the transfer was not performed according to these requirements.