Failure to Provide Required Assistance During Resident Transfers Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident, who was at risk for falls due to functional decline, weakness, and bedbound status, did not receive the required assistance from two staff members during transfers as specified in her care plan. The resident's care plan, updated shortly after admission, clearly indicated the need for two-person assistance during transfers and for staff to lock wheelchair brakes. Despite these interventions, the resident reported pain after a transfer, and subsequent X-rays confirmed a new acute nondisplaced left tenth rib fracture. The resident stated that the aide performing the transfer squeezed too tightly and that only one staff member was present during the transfer, contrary to the care plan requirements. Further review of the resident's medical record and interviews revealed that the resident continued to be dependent on staff for transfers and had intact cognition. Additional incidents were noted, including an event where the resident had to be lowered to the floor during a transfer because a wheelchair brake was not locked, again with only one staff member present. Staff interviews and documentation confirmed that the required two-person assistance was not consistently provided, and there was a lack of written documentation or retraining for staff involved in these incidents. Radiological evidence confirmed that the rib fracture was a new injury, not related to any prior incident before admission. The facility's investigation was unable to identify the specific staff member responsible for the July transfer that resulted in the fracture. The facility's policy required that residents unable to perform activities of daily living independently receive necessary services and assistance in accordance with their care plan, which was not followed in these instances.