Failure to Prevent Skin Tears During Resident Transfers
Penalty
Summary
A resident with a history of multiple skin tears and impaired skin integrity sustained a significant injury during a transfer from wheelchair to bed. The certified nursing assistant (CNA) involved reported noticing a blood stain on the resident's sock and, upon removing it, discovered a fresh wound on the left lower leg. The wound was later assessed as a large skin tear requiring 11 stitches, and the resident was transferred to the emergency room for treatment. Interviews with staff and the resident's daughter confirmed that the injury occurred during the transfer process, with the CNA unable to specify exactly how the injury happened. The resident's medical doctor and wound care nurse both confirmed the injury was sustained during the transfer. The resident's records indicate a pattern of similar incidents, including multiple previous skin tears and bruises occurring during transfers and repositioning. The care plan documented the resident's dependence on staff for transfers due to activity intolerance and dementia, requiring a two-person assist. Despite these documented needs and a policy requiring safe transfer practices, the resident continued to experience skin injuries during care, culminating in the significant laceration that required emergency intervention.