Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who had a care plan requiring two staff members to assist with stand pivot transfers and the use of Dermasaver skin tubes while out of bed, was transferred by a single staff member. The resident was found in bed with a large skin tear on the right lower leg after being out of bed in a wheelchair for dinner. Facility records and staff statements confirmed that the assigned LNA transferred the resident out of bed to a chair alone and did not transfer the resident back to bed. The skin tear was discovered by the primary LNA upon the resident's return to bed, and the facility's internal investigation determined that the injury occurred during the unsupervised transfer, which was not in accordance with the resident's care plan.