Failure to Provide Required Assistance During Transfer Results in Resident Injury
Penalty
Summary
Facility staff failed to provide adequate assistance during a transfer of a resident from a wheelchair to a bed, resulting in the resident sustaining injuries that required hospitalization. The resident, who had diagnoses including unspecified dementia, chronic atrial fibrillation, and muscle weakness, was assessed as dependent on staff for transfers and required a two-person physical assist. Despite this documented need, a certified nurse aide (CNA) attempted to transfer the resident alone, without the required assistance. During the transfer, the CNA did not remove the wheelchair footrests and attempted to move the resident quickly to avoid soiling her clothes due to the resident's incontinence episode. As a result, the resident struck his face and sustained a hematoma to the right lower leg. The resident was found bleeding from the nose and mouth, and a hematoma was noted on the right leg. The resident was subsequently transferred to the emergency room, where further evaluation revealed a right lower extremity hematoma with necrosis, requiring surgical debridement and wound vac placement. Prior to the incident, the resident had no documented skin issues or wounds, and regular skin assessments indicated skin integrity was intact. The CNA involved admitted to transferring the resident alone and not following proper safety protocols, including neglecting to remove the wheelchair footrests. The incident was reported to the state agency, and facility documentation confirmed that the resident's care plan and assessments required a two-person assist for transfers, which was not followed at the time of the event.