Failure to Use Required Assistive Device During Resident Transfer Results in Injury
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards by not providing the proper assistive devices during a transfer. Specifically, two CNAs assisted a resident with a history of impaired vision, generalized weakness, and previous falls with a right hip fracture, from her bed to a wheelchair without using the required rolling walker as specified in her care plan. During the transfer, the resident's legs became weak, and she was lowered to the floor, resulting in her right leg going underneath her. Following the incident, the resident initially showed no signs of injury, but later complained of pain and was found to have bruising and edema in her right leg. She was subsequently transferred to the hospital, where she was diagnosed with a right tibial plateau fracture. The care plan for the resident clearly indicated the need for extensive assistance from two staff members and the use of a rolling walker during transfers, which was not followed during the incident. Interviews with the involved CNAs revealed that neither had checked the resident's care plan prior to the transfer, and both admitted to not using the walker. One CNA stated she had never transferred the resident before and questioned the technique used, while the other CNA, who had transferred the resident previously, also did not use the walker and had not reviewed the care plan. The facility's policy emphasized the importance of using assistive devices and providing adequate supervision to prevent accidents, which was not adhered to in this case.