Failure to Use Proper Transfer Technique for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dementia, Alzheimer's disease, osteoarthritis, and a history of right femur fracture, was not transferred safely by staff. The resident was identified as high risk for falls and required substantial to maximal assistance for transfers, as documented in her care plan and Minimum Data Set. Despite these requirements, two CNAs transferred the resident from her chair to her bed by holding her under the arms and by the waistband of her pants, without the use of a gait belt. The resident did not bear any weight during the transfer. Interviews with the Director of Nursing and one of the CNAs confirmed that facility policy requires the use of a gait belt for transfers involving two staff members, and that a mechanical lift should be used if the resident is unable to stand. The facility's own guidelines specify the proper use of a gait belt and recommend a mechanical lift for non-weight-bearing residents. The observed transfer method did not follow these protocols, creating a situation where the resident could have been injured.