Failure to Use Required Lift Results in Resident Injury During Transfer
Penalty
Summary
The facility failed to ensure a resident was transferred safely in accordance with her assessed needs, resulting in a traumatic injury. Despite the resident being assessed as dependent for transfers and requiring a total lift, two staff members performed a manual transfer from bed to wheelchair without using the mechanical lift. The resident and her representative both informed staff that a lift was required, but staff proceeded to manually slide the resident, during which her legs and torso slipped downward and her right leg struck the exposed metal of the wheelchair armrest slot, causing a laceration. Staff involved in the transfer acknowledged not questioning the presence of a sling pad in the wheelchair and did not consult the nurse supervisor for clarification. The resident, who was cognitively intact and had a diagnosis of alcoholic cirrhosis of the liver with ascites, sustained a trauma laceration to her right leg, measured at 4.5 cm x 5.5 cm x 0.2 cm, as confirmed by the treatment nurse. The facility's policy required the licensed nurse to determine and communicate the level of assistance needed for safe transfers, but the resident's transfer status was not reflected on the Kardex for staff reference. The risk manager confirmed that the resident was not transferred according to her assessed needs and acknowledged that this failure could lead to accidents.