Failure to Use Safe Transfer Techniques for High-Risk Resident
Penalty
Summary
Staff failed to use safe transferring techniques for a resident with a history of multiple falls and significant physical and cognitive impairments. The resident, who had diagnoses including renal insufficiency, neurogenic bladder, diabetes mellitus, cerebrovascular accident, and chronic pain, required substantial assistance for transfers and was care planned for two-person assistance. Despite this, on one occasion, only one staff member assisted the resident in transferring from the toilet to a wheelchair, resulting in the resident sliding to the floor. The care plan had been updated to specify two-person assistance for transfers, especially when no grab bar was available, and therapy recommendations also indicated the need for two staff during transfers. Interviews with staff revealed inconsistent understanding and implementation of the required level of assistance, with some staff unsure whether one or two people were needed for transfers. Documentation showed previous incidents where the resident was found on the floor or lowered to the floor during transfers, and interventions were put in place to address these risks. However, the failure to consistently follow the care plan and therapy recommendations led to another fall event. The facility's policy required individualized fall risk assessment and care planning, but these were not effectively implemented for this resident.