Failure to Provide Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including metabolic encephalopathy, gastrointestinal hemorrhage, and limited mobility, was not safely transferred by staff. The resident's care plan required assistance from two staff members for pivot transfers using a front wheeled walker (FWW) and gait belt, with staff responsible for blocking the resident's feet and providing verbal cues due to visual deficits. Despite these requirements, the resident was transferred without a gait belt, and the transfer was not performed according to the care plan instructions. During the incident, two CNAs were involved in transferring the resident to a recliner. The resident reported that the staff did not use a gait belt and did not provide adequate assistance, resulting in her missing part of the wheelchair seat and striking her leg on the wheelchair, causing a deep laceration that required nine stitches. Blood was later found on the foot pedal pegs of the wheelchair, supporting the conclusion that the injury occurred during the unsafe transfer. The resident expressed that she did not feel safe during the transfer and had not previously met the staff involved. Interviews and record reviews revealed inconsistencies in staff accounts, with one CNA stating she used a sit-to-stand lift by herself and another indicating the resident refused to transfer with a gait belt. The investigation determined that the staff failed to follow the resident's care plan and facility policy for safe transfers, including the use of a gait belt and ensuring proper clearance from wheelchair components. The incident was not immediately reported to nursing staff, and the resident's complaints of pain were not promptly addressed.