Unsafe Transfer Practices Result in Resident Distress
Penalty
Summary
The facility failed to provide safe transfer procedures for a resident who was unable to bear weight on their lower extremities and required total assistance. During an observed transfer from bed to wheelchair, three CNAs assisted the resident using a loose-fitting gait belt placed around the upper body, while two CNAs lifted the resident under the arms, causing the resident to moan and grimace in pain. The resident's care plan indicated a two-person assist for transfers, but the method used placed undue stress on the resident's arms and shoulders, and the resident was unable to communicate their pain level. Staff interviews revealed that CNAs had reported the resident's decline and the need for a mechanical lift to the charge nurse and hospice staff over the preceding months, expressing concerns for both resident and staff safety. Despite these reports, the care plan and transfer method were not updated to reflect the resident's increased needs. The interdisciplinary team meetings did not document discussion of transfer needs, and there was a lack of timely reassessment and adjustment of the transfer process, even as staff recognized the resident was no longer able to assist in transfers.