Resident Injury Due to Improper Transfer and Communication Breakdown
Penalty
Summary
A resident sustained a significant injury to the left lower extremity, including swelling and bruising described as the size of a tennis ball, after being transferred incorrectly by staff. The incident occurred when staff attempted to transfer the resident from a wheelchair to bed without using the required hoyer lift, instead performing a stand pivot transfer with a gait belt and three staff members present. The transfer was made more difficult because the resident was very weak, and the proper sling for the hoyer lift was not in place. The nurse documented the injury and noted the resident reported an accident had occurred. Review of the resident's care plan showed it was outdated, indicating the resident could transfer with one person assisting, with no updates reflecting the current need for a hoyer lift. Staff interviews revealed confusion and lack of communication between nursing and therapy staff regarding the resident's transfer status. Therapy had used a slider board earlier in the day and did not leave a sling under the resident, which contributed to the improper transfer method being used by nursing staff. The facility's investigation determined the injury likely resulted from this difficult and incorrect transfer.