Failure to Use Gait Belt and Dry Resident During Transfer Results in Serious Injury
Penalty
Summary
A deficiency occurred when facility staff failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision and assistive devices during a transfer. Specifically, a male resident with left-sided hemiplegia, vascular dementia, and aphasia required substantial assistance for transfers and was dependent on staff for mobility and toileting. During a transfer from a shower chair to a wheelchair, staff did not use a gait belt as required by facility protocol, and the resident was not dried off prior to the transfer, resulting in the resident slipping and sustaining a comminuted fracture to the left humeral neck and glenoid bone. The incident was not immediately reported or documented in the facility's records. The resident did not report the incident until several days later, and there was no evidence in the facility's incident log or electronic health record of a fall, near fall, or injury during the relevant period. Staff involved in the transfer stated that the resident began to slip but was caught before falling, and no pain or injury was reported at the time. However, subsequent medical evaluation revealed significant fractures, and the resident required additional pain management and orthopedic consultation. Interviews with staff and review of facility policy confirmed that the use of a gait belt and ensuring the resident was dry before transfer were required safety measures that were not followed. The facility's policy also required ongoing assessment of residents' transfer needs and proper documentation, which was not evident in this case. The failure to adhere to established protocols and to document and report the incident led to the identification of an Immediate Jeopardy situation.