Failure to Prevent Skin Tears During Resident Transfers
Penalty
Summary
The facility failed to provide adequate care and supervision during resident transfers, resulting in skin tears for two residents. One resident, with diagnoses including atrial fibrillation, prostate cancer, congestive heart failure, anxiety, COPD, and hypertension, was cognitively intact and required maximum staff assistance for mobility and transfers. This resident sustained a skin tear to the right forearm/wrist area after staff wheeled him into the bathroom and his arm was bumped against the doorframe during the transfer process. The incident was reported by staff and confirmed by the DON. Another resident, with a history of hypertensive heart disease, congestive heart failure, cardiomyopathy, and diabetes, had moderate cognitive impairment and also required substantial staff assistance for transfers. This resident received a skin tear to the left elbow during a transfer when staff were reportedly rushing to move her from the bathroom. The injury was documented in the medical record and confirmed by the DON. Both incidents were identified through medical record review, staff and resident interviews, and facility incident reports.