Failure to Prevent Accidents During Resident Transfers
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, difficulty walking, severe cognitive impairment, and osteoporosis experienced two preventable injuries during transfers. The first incident took place in a common bathroom, where the resident's right ankle was injured during a transfer, resulting in swelling, pain, and a possible stress fracture. The investigation revealed that the footrests of the wheelchair were not removed during the transfer, and the resident's foot became caught, causing the injury. At the time, there was no evidence of a care plan addressing transfer needs for the resident. Following the first incident, there was no update to the resident's care plan to address transfer safety, and the resident did not receive a therapy referral. Staff were verbally reminded about safe transfer practices, but documentation shows that the care plan was not revised until several weeks later. Despite the resident's high risk for injury and the family's request for two-person assistance during transfers, these interventions were not implemented prior to the second incident. A second incident occurred when a CNA attempted a one-person transfer of the resident from a wheelchair to a bed. During this transfer, the resident's left leg became caught, resulting in a pop sound and severe pain. The resident was subsequently found to have sustained tibia and fibula fractures, requiring hospital treatment and surgery. Interviews with staff and the resident's family indicated that the transfer was performed too quickly, the resident's requests to slow down were not heeded, and language barriers may have contributed to communication difficulties during the transfer.