Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure that staff followed appropriate transfer techniques and provided adequate supervision and assistive devices to prevent accidents, resulting in a resident sustaining rib fractures after a fall during an improper transfer. The resident, who had a history of falls and required substantial/maximal assistance for transfers, was being assisted by a CNA from bed to wheelchair. During the transfer, the CNA positioned herself at the side of the resident due to limited space, rather than in front as per facility training and policy. The resident was wearing slip-on shoes with no backs, and as she pivoted, her shoe became lodged on a wheelchair wheel, causing her to lose balance and fall forward to the floor. The CNA was unable to prevent the fall due to her position and the obstruction caused by the wheelchair and room layout. The incident report and staff interviews confirmed that the CNA did not follow the facility's in-service training, which instructed staff to stand in front of the resident, use a gait belt properly, and ensure the resident wore appropriate footwear during transfers. The care plan for the resident required a one-person transfer with a gait belt but did not specify the need for proper footwear. The CNA admitted to using a side-assist technique and acknowledged she should have been in front of the resident. Other CNAs interviewed stated that standing in front of the resident was the safest method and allowed them to better protect the resident from falls. The facility's policies and training materials emphasized the importance of proper positioning and use of gait belts during transfers to minimize fall risk. Following the fall, the resident was assessed and found to have a hematoma and bruising on her face and head. She was later transferred to the hospital, where imaging revealed acute, mildly displaced fractures of the left anterior third rib and a non-displaced fracture of the left anterior fourth rib, in addition to facial bruising. The resident was cognitively intact and had no impairments in range of motion but required significant assistance for transfers due to weakness and other medical conditions. The failure to adhere to established transfer protocols and ensure the use of appropriate footwear directly contributed to the resident's fall and subsequent injuries.