Failure to Provide Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Alzheimer's disease, and dementia, who was dependent on staff for all mobility except rolling in bed, did not receive a safe transfer as required by her care plan. The resident's care plan and therapy recommendations specified that she required two-person physical assistance and a gait belt for transfers. Despite these documented requirements, an investigation revealed that a Certified Nurse Aide (CNA) likely transferred the resident alone, contrary to the established plan of care and facility policy. Following this transfer, the resident was found to have reddish discoloration and bruising on both hands and wrists, as well as a small skin tear on the top of her left hand. These injuries were first reported by the resident's daughter/Power of Attorney and subsequently assessed by nursing staff, who documented the presence of bruising, discoloration, and a skin tear. The incident was reported to the Medical Doctor, Director of Nursing, and Administrator, and the injuries were treated according to standard wound care procedures. The facility's investigation concluded that the CNA, who was working her last shift and had already resigned, did not follow the resident's care plan by transferring her without the required second staff member and without using a gait belt. The CNA denied the allegation, but the facility marked her as ineligible for rehire. The transfer policy in place at the facility required adherence to the care plan and proper transfer techniques, which were not followed in this instance, resulting in the resident's injuries.