Failure to Ensure Competent Resident Transfer Leading to Injury
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in the skills and techniques necessary to safely transfer a resident, as identified through resident assessments and described in the plan of care. Specifically, a nurse aide did not use a gait belt, did not position herself correctly, and attempted a one-person transfer for a resident who required substantial/maximal assistance, which typically necessitates two staff members. The aide stood behind the resident during the transfer, contrary to facility policy and standard practice, and did not verify the resident's transfer requirements in the Kardex prior to the transfer. The resident involved was an elderly male with multiple diagnoses, including vascular parkinsonism, atrial fibrillation, dysphagia, unsteadiness, muscle weakness, intellectual disabilities, and dementia. He was assessed as a high fall risk, had severe cognitive impairment, and required substantial/maximal assistance for transfers according to his care plan and MDS. On the day of the incident, the aide attempted to transfer the resident from bed to wheelchair using a stand-and-pivot method without a gait belt and without a second staff member. During the transfer, the resident's leg slid, and he was assisted to the ground by the aide, resulting in a fall. Following the incident, the resident was found to have right hip tenderness, swelling, and severe pain, and was subsequently transferred to the hospital where he was diagnosed with a right femoral shaft fracture requiring surgical intervention. Interviews with other staff and therapy personnel confirmed that the standard procedure was to use a gait belt and have staff positioned in front of the resident during transfers, and that substantial/maximal assistance required two staff members. The aide involved did not follow these procedures, and her actions were inconsistent with both facility policy and her prior training.