Resident Injury Due to Exposed Bed Frame and Improper Transfer Technique
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and had multiple medical conditions including acute kidney failure, diabetes, COPD, CHF, anxiety, depression, anemia, and atrial fibrillation, sustained a significant injury during a transfer. The resident, who was moderately cognitively impaired, required the assistance of two staff members for transfers. During a transfer from a wheelchair to bed, the resident's left leg scraped against an exposed piece of metal on the bed frame, resulting in a 10-centimeter laceration that required 10 sutures to close. The exposed metal was due to a missing protective plastic cap on the bed frame joint. Facility policy required that all equipment, including beds, be maintained in a safe and functional condition, with regular inspections to ensure safety. However, the bed in question was found to be several years old, and some of the protective plastic caps had come off, leaving sharp metal edges exposed. Staff interviews confirmed that the exposed metal was present at the time of the incident and that the injury was directly caused by contact with this hazard during the transfer process. Additionally, it was determined that the staff members involved in the transfer did not use a gait belt, which was required by facility policy to ensure resident safety during transfers. Both CNAs involved in the incident reported that the resident's leg caught on the exposed metal as they physically lifted the resident into bed, and neither had used a gait belt during the process. The lack of proper equipment use and the presence of an environmental hazard directly contributed to the resident's injury.