Failure to Update and Communicate Resident Transfer Requirements Leads to Injury
Penalty
Summary
A deficiency occurred when a resident, who had a history of falls and required the assistance of two staff members for transfers following a recent fall, was transferred by only one staff member. The resident's care plan had been updated to reflect the need for two-person assistance with a gait belt after her knee gave out during a previous transfer. However, the care sheet in the resident's room incorrectly indicated that only one staff member was needed for transfers. As a result, a staff member, relying on the outdated care sheet, attempted to transfer the resident alone using a gait belt and walker, rather than following the updated care plan requirements. During this transfer, the resident sustained an injury to her fourth toe, which became bruised and later developed a blackened toenail. The staff member involved was unaware of the updated transfer requirements in the electronic care plan and used the information from the care sheet in the resident's room. The incident highlighted a failure to ensure that staff had access to and followed the most current care plan information, leading to inadequate supervision and an accident during a transfer.