Resident Sustains Severe Leg Laceration During Unsafe Transfer
Penalty
Summary
A resident sustained a 10-12 centimeter laceration to the left lower leg requiring 18 sutures during a transfer from wheelchair to bed. The incident occurred when a CNA was transferring the resident, and the resident's leg was closest to the bed. During the pivot, the resident expressed pain, and the CNA observed a significant laceration with substantial bleeding. It was unclear whether the injury was caused by contact with the bed or the wheelchair. Blood was later found on the bedframe, and medical documentation confirmed a large skin tear due to trauma during the transfer. Interviews with staff revealed uncertainty regarding whether the wheelchair footrests were in place at the time of the incident. The facility did not have specific policies for resident transfers or fall prevention, providing only a gait belt policy that lacked comprehensive guidance on safe transfer techniques, resident mobility, staff body mechanics, or injury prevention. The absence of clear protocols contributed to the unsafe transfer and subsequent injury.