Failure to Provide Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments and a documented need for maximum assistance of two staff for transfers was transferred by a single certified nurse aide (CNA) without the use of a gait belt. The resident, who had diagnoses including unsteadiness on feet, muscle weakness, osteoarthritis, and polyneuropathy, was dependent on staff for mobility and required hands-on assistance for all transfers, as documented in the care plan and quarterly assessment. On the day of the incident, the resident activated the call light for assistance to use the bathroom, and the CNA responded alone, transferring the resident from the wheelchair to the toilet using a 'bear hug' technique without a gait belt. During the transfer, the resident became weak and complained of left arm pain immediately after being seated on the toilet. The CNA later stated that they believed the resident required only one-person assistance, despite documentation indicating a two-person assist was necessary. The CNA also confirmed that a gait belt was not used during the transfer, contrary to facility policy, which requires gait belts for all hands-on transfers unless contraindicated. The Director of Nursing confirmed that multiple communication methods were in place to inform staff of residents' transfer status, and there were no staffing shortages at the time of the incident. Following the transfer, the resident exhibited severe pain and was sent to the hospital, where an acute fracture of the left upper arm was diagnosed. Medical records and staff interviews confirmed that the injury was consistent with improper transfer technique and lack of appropriate assistance. The resident, who previously experienced minimal pain, reported daily pain following the incident and was placed on a non-weight bearing order for the affected arm.