Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to transfer a resident according to her Care Plan, resulting in a significant injury. The resident, who had diagnoses including atrial fibrillation, heart failure, and osteoporosis, and was severely cognitively impaired, was dependent on staff for chair-to-chair transfers. Her Care Plan and therapy recommendations required transfers with the assistance of one staff member, a gait belt, and a walker. However, during a transfer from a recliner to a wheelchair, staff did not use the walker as directed. During the transfer, the resident's left leg became caught on a sharp part of the wheelchair's foot pedal, which was obstructed from folding back fully due to a bag hanging on the side. This resulted in a deep laceration to the resident's left leg, causing significant bleeding. The resident was on anticoagulation therapy (Eliquis), which contributed to acute blood loss anemia and necessitated emergency medical intervention, including sutures to control arterial bleeding and a blood transfusion. Interviews with staff revealed inconsistent practices regarding the removal or repositioning of wheelchair pedals during transfers, and it was confirmed that the walker was not used during the incident. The staff member involved acknowledged not following the Care Plan instructions. Observations also noted that the wheelchair pedal was sharp and that the bag hanging on the side prevented the pedal from moving out of the way, directly contributing to the injury.