Failure to Investigate and Prevent Resident Injury During Wheelchair Transfer
Penalty
Summary
A resident with severe cognitive impairment sustained bruising to the left third and fourth fingers after a certified nursing assistant (CNA) failed to ensure the resident's hand was inside the wheelchair during a transfer from the dining room table. The CNA admitted to pinching the resident's fingers between the table and the wheelchair, resulting in dime-sized purple bruises. The incident was observed and reported by therapy staff, and the resident was noted to have no pain or issues with finger movement at the time of assessment. Despite the injury, the facility did not complete a Risk Watch Occurrence Form, conduct an investigation into the cause of the injury, or update the resident's care plan with interventions to prevent future injuries. The facility's policy requires immediate care, monitoring, notification of physician and family, completion of an occurrence report, and documentation of the facts and witness statements for any incident or accident affecting a resident. These steps were not followed in this case, as confirmed by the facility administrator.