Failure to Prevent Accidents During Resident Transport and Transfers
Penalty
Summary
The facility failed to ensure that wheelchair leg rests were in place during the transport of a resident, resulting in an accident. One resident with a history of cerebral infarction, narcolepsy, anemia, peripheral vascular disease, and muscle weakness was dependent on staff for transfers and wheelchair mobility. During transport by a recreation aide, the resident's left leg became caught under the wheelchair because the leg rests were not used, despite facility expectations that leg rests be in place during transport. The aide confirmed that the leg rests were not in use at the time of the incident, and the director of nursing services acknowledged that this failure could result in accidents or injuries. Another deficiency involved the improper transfer of a resident with dementia, atrial fibrillation, anemia, and feeding difficulties. This resident required maximal assistance for transfers and was care planned to use a rolling walker with one staff assist. During a transfer from wheelchair to bed, the nurse aide did not use the required rolling walker or a gait belt, and allowed the resident to hug her during the transfer. The resident was exhausted and unable to follow directions, but the aide did not seek additional help or notify the charge nurse. As a result, the resident's right lower leg was lacerated, requiring emergency care and staples to close the wound. The director of nursing and regional clinical nurse confirmed that the transfer was not performed as ordered and that the lack of assistive device use contributed to the injury. In both cases, the facility did not provide documentation of a wheelchair transport policy when requested. The failures to follow established care plans and transfer techniques, as well as the lack of required equipment use during resident transport and transfers, directly led to accidents and injuries for the residents involved.