Failure to Provide Safe Transfer Leading to Resident Injury
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including vascular parkinsonism, dementia, muscle weakness, and severe cognitive impairment, was not provided with adequate supervision and assistive devices during a transfer. The resident was assessed as a high fall risk, required substantial/maximal assistance for transfers, and had a care plan indicating the need for staff participation during transfers. However, the care plan did not specify the use of a gait belt for transfers. The resident's transfer needs were documented in the Kardex, but this information was not reviewed prior to the incident due to the resident's discharge. On the day of the incident, a CNA attempted to transfer the resident using a stand and pivot method without the use of a gait belt and performed the transfer alone, standing behind the resident rather than in front as per facility policy and standard practice. During the transfer, the resident's leg slid, and the CNA helped the resident to the ground, resulting in the resident falling forward to his knees. The resident sustained a right femoral shaft fracture, which required surgical intervention. Interviews with staff and therapy personnel confirmed that transfers should always be performed with a gait belt, with staff positioned in front of the resident, and that substantial/maximal assistance requires two staff members. The CNA involved stated she did not use a gait belt because she was not told it was needed and typically transferred the resident from behind, which was not consistent with facility policy or standard practice. Other staff interviews confirmed that the correct procedure was not followed, and that the Kardex should be used to determine transfer requirements. The incident was identified as an Immediate Jeopardy situation due to the failure to provide adequate supervision and assistive devices, resulting in a serious injury to the resident.