Failure to Provide Safe Transfer Assistance and Proper Use of Equipment Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure residents received appropriate assistance with transfers and proper use of transfer equipment, resulting in actual physical harm to two residents. In one instance, a resident with multiple complex medical conditions, including multiple sclerosis, morbid obesity, and an above-knee amputation, was dependent on staff for all transfers. During a transfer to bed using a sit-to-stand lift, the sling was not applied correctly, and only one CNA was present to operate the lift. The resident subsequently developed significant bruising, a hematoma, fractured ribs, and anemia from blood loss, requiring hospitalization and a blood transfusion. In another case, a resident with diagnoses including heart failure, diabetes, and chronic kidney disease required staff assistance for transfers and ambulation. A CNA assisted the resident to the bathroom without using a gait belt, as required by facility policy. When the resident began to fall, the CNA attempted to support the resident by holding her under the arms and laying her down, resulting in a dislocated shoulder. The resident was found on the floor, unresponsive to commands, and was transferred to the hospital, where a shoulder dislocation was diagnosed and surgical intervention was recommended but declined by the resident and family. Both incidents were confirmed through record review, interviews, and facility investigations. The facility's own policies required the use of gait belts during transfers and ambulation, and proper use of mechanical lifts, but these protocols were not followed in the cases reviewed, directly leading to significant injuries for the residents involved.