Improper Transfer Technique Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with diagnoses of weakness, muscle weakness, chronic fatigue, osteoarthritis, and chronic pain was not transferred safely by staff. The resident, who requires one-person assistance and a gait belt for transfers, was found with a large, dark purple/red bruise encircling her right forearm. The resident reported that during a nighttime transfer, a CNA pulled her by the arm to help her out of bed, rather than using the gait belt as required by her care plan. The CNA involved stated it was her first time assisting this resident at night and that she believed the resident could stand with a walker, so she assisted her to stand and then held the gait belt, but did not describe using the gait belt during the initial transfer from bed. Other staff members familiar with the resident confirmed that proper transfer technique involves the use of a gait belt and that the resident should not be pulled by the arms. The facility's policy also requires staff to use gait belts for non-mechanical transfers. The improper handling was corroborated by staff observations and interviews, as well as the resident's own account, which indicated that the transfer was rough but not intentionally abusive. The incident resulted in significant bruising to the resident's forearm.