Failure to Assess and Determine Root Cause of Skin Impairment During Transfers
Penalty
Summary
The facility failed to thoroughly assess and determine the root cause of a skin impairment for a resident reviewed for skin management. During an unannounced onsite investigation, a resident with hemiplegia and bipolar disorder, who was dependent on staff for transfers, reported that staff were rough when transferring them to a wheelchair, causing pain to their arms. The resident expressed fear and anxiety about reporting these incidents, stating they did not want to get anyone in trouble. Observation revealed the resident held their left hand tightly against their chest, with uncertainty about their ability to straighten the arm, while the right arm was freely movable. At the time of observation, no visible bruising or skin impairments were noted on the arms. The clinical record review confirmed the resident's dependency on staff for transfers and intact cognition.