Untrained Staff Use of Resident-Owned Transfer Device Results in Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with paraplegia, muscle weakness, and impaired lower extremity range of motion was not provided with adequate supervision and assistive devices to prevent accidents. The resident required partial to moderate assistance for transfers and had a care plan indicating the need for staff assistance and the use of a sit-to-stand device, which was later discontinued. The sit-to-stand device used for the resident's transfer was the resident's personal property and not owned by the facility, and there was no manual available for staff training on its use. On the day of the incident, a hospitality aide who was not trained or competency-checked for transfer skills or the use of the sit-to-stand device attempted to transfer the resident to the bathroom. The aide had previously informed the resident of her lack of training, but proceeded with the transfer at the resident's urging. During the transfer, the aide was unable to properly position the resident, and the resident's legs gave out, resulting in a fall and a left knee fracture. The aide was unable to use a gait belt and had difficulty maneuvering the device in the small bathroom. Another aide, also untrained on the device, assisted in lifting the resident from the floor. The hospitality aide's job description did not include performing resident transfers, and the facility's policy required the use of a gait belt for all transfers. The administrator and therapy staff were unaware that untrained staff were using the resident's personal transfer device, and there was no documentation of staff training or competency checks for the equipment. The incident was confirmed through video evidence, staff interviews, and record review, revealing that the lack of proper training, supervision, and equipment ownership led to the resident's injury during the transfer.