Failure to Ensure Safe Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure an environment free from accident hazards for a resident who required staff assistance and a mechanical lift for safe transfers. The resident, who had multiple diagnoses including pleural effusion, COPD, rheumatoid arthritis, polyosteoarthritis, and osteoporosis, was dependent on staff for transfers, toileting, and mobility. The care plan indicated the need for a Hoyer lift for transfers, but also noted the resident often declined its use, in which case two staff and a gait belt were to be used. On the day of the incident, the resident declined both the Hoyer lift and gait belt, insisting on standing and pivoting for the transfer. During a shower transfer, two CNAs assisted the resident, who requested to be scooted back in the shower chair. The CNAs placed their arms under the resident's arms and attempted to move her back, at which point a popping noise was heard and the resident experienced severe pain in her right upper arm. The CNAs did not use a gait belt during this maneuver, and their arms were misplaced in relation to the resident's arms. The incident resulted in a humerus fracture, confirmed by hospital assessment and subsequent surgery. Staff interviews confirmed that proper transfer techniques were not followed, as staff are trained not to lift residents by or under the arms due to the risk of injury. The care plan and therapy notes specified the use of mechanical lifts or, if refused, a gait belt with two staff. Despite these instructions, the transfer was performed without the required equipment, directly leading to the resident's injury.