Failure to Ensure Safe Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of falls, severe cognitive impairment, muscle weakness, and unsteadiness was not safely transferred using a mechanical lift device. The resident, who required substantial to maximal assistance for transfers and had a care plan indicating a high risk for falls, was being assisted by a CNA who did not use a gait belt during the transfer process. The CNA positioned the lift too close to the bed, making it difficult to lower the seat paddles, and subsequently moved the lift without the paddles in place. During this process, the resident let go of the bar and fell to the floor, resulting in a displaced fracture of the right femur. Interviews with staff revealed that the use of a gait belt was required during such transfers, and that the CNA was aware of this requirement but failed to implement it. The CNA also acknowledged that the resident had complained of arm pain prior to the transfer and that she should have considered using a different transfer method or sought additional assistance. Other staff members confirmed that a gait belt should always be used, especially for residents who are unpredictable or have a history of falls, and that two staff members may be needed for such transfers. Documentation and policy review showed that the facility's procedure for using the lift device included locking the casters, ensuring the resident's feet were on the platform, and using a gait belt to assist the resident in standing before lowering the seat paddles. The resident's care plan and assessment indicated a need for extensive assistance and highlighted her fall risk, but these precautions were not followed during the incident, directly leading to the resident's fall and injury.