Improper Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with significant medical conditions, including Parkinson's Disease, dementia, muscle weakness, and a history of brain stem stroke, was improperly transferred using a sit-to-stand mechanical lift. The resident was cognitively impaired and required substantial to maximum assistance for bed-to-chair transfers. During a transfer, the resident complained of leg pain, and staff discovered a bleeding laceration on the resident's leg, which ultimately required emergency room treatment and 14 sutures. Review of the incident revealed that two CNAs were involved in the transfer. One CNA reported that the resident complained of pain after being placed on the bed, and upon inspection, blood was found on the resident's pants. The other CNA could not recall the exact sequence of events but confirmed the use of the sit-to-stand lift and was unsure if the resident's leg had come into contact with the bed frame or another object. Staff interviews and documentation indicated uncertainty about the precise cause of the injury, with some suggesting the injury may have resulted from pressure or contact with equipment during the transfer process. Further investigation by facility leadership and therapy staff found no sharp edges on the bed or lift, but it was determined that the laceration likely occurred during the transfer, possibly due to a crushing injury or scraping against the wheelchair or bed frame. The incident log, witness statements, and staff interviews all confirmed that the injury was associated with the transfer process and that the resident's condition, including edema, may have contributed to the severity of the injury. There was a lack of correlating progress notes documenting the incident that led to the emergency room visit and subsequent treatment.