Improper Transfer Technique and Failure to Document Change in Skin Condition
Penalty
Summary
Staff failed to provide appropriate care and treatment for a resident in two key areas. During a transfer from wheelchair to bed, two CNAs lifted the resident by placing their arms under the resident's armpits and holding the back of the resident's pants, rather than using a gait belt as required. The Director of Rehab confirmed that a gait belt should have been used and that there was no gait belt available in the resident's room at the time of the transfer. The CNAs stated they had been trained by therapy to transfer the resident in this manner, despite facility policy and standard practice. Additionally, a change in the resident's skin condition was not documented as required by facility policy. The resident was found to have a superficial break in the skin and redness on the right big toe. The LVN responsible for wound care was unaware of this change, and the CNA who observed the wound during the resident's morning shower did not document it. Review of the medical record confirmed there was no documentation of the change in skin condition.