Failure to Provide Adequate Supervision During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent an injury to a resident with chronic obstructive pulmonary disease and Alzheimer's disease, who required partial to moderate assistance for transfers and had a physician order for one-person assist with a rolling walker. During a stand-to-pivot transfer from bed to wheelchair, the resident became weak, buckled at the knees, and was assisted by a nurse aide into the wheelchair. After the transfer, it was discovered that the resident had sustained a deep laceration to the right lower leg, which was bleeding profusely. The laceration was caused by the resident's leg coming into contact with the wheelchair's leg rest hinge bracket during the transfer. Immediate first aid was provided, and the resident was sent to the emergency department, where the wound required multiple staples, sutures, and application of hemostatic dressings due to continued bleeding. The injury resulted in repeated hospital visits within a short period due to ongoing bleeding from the wound site. Documentation and staff interviews confirmed that the transfer was performed with a single staff member as per the care plan at the time, but the incident revealed that this level of assistance was insufficient to prevent injury for this resident. The facility's failure to provide adequate supervision and appropriate transfer assistance directly led to the resident sustaining actual harm in the form of a significant laceration requiring medical intervention.