Failure to Use Safe Transfer Methods and Care Plan Resident Preferences
Penalty
Summary
Staff failed to ensure a resident was transferred in a manner that prevented possible injury and did not include the resident's specific transfer needs or preferences in the care plan. The resident, who had a history of heart failure, atrial fibrillation, tricuspid valve insufficiency, depression, and a previous hip fracture, required substantial assistance with transfers and was at risk for falls, pain, and impaired skin integrity. The care plan did not specify the method of transfer, the number of staff required, or address the resident's preferences or refusals related to transfer assistance. Interviews and record reviews revealed that staff were trained to use gait belts for resident transfers, as outlined in facility policy. However, staff reported that the resident often refused the use of a gait belt, stating it was uncomfortable. Instead, staff used an unsafe 'hug' technique, where the resident placed their arms around the staff's neck and the staff lifted the resident under the arms. Multiple staff, including CNAs, LPNs, RNs, and nursing leadership, acknowledged that this method was not appropriate and did not align with facility policy or safe transfer practices. Despite the resident's refusal to use a gait belt, there was no documentation in the care plan regarding the resident's transfer preferences or refusals, nor was there an alternative safe transfer method identified. Staff continued to use the unsafe technique, and leadership confirmed that the resident required a gait belt for all transfers due to weakness. The lack of individualized care planning and failure to follow safe transfer procedures resulted in the area not being free from accident hazards and did not provide adequate supervision to prevent accidents.