Failure to Ensure Safe Transfer Techniques and Adequate Supervision
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents during transfers. Specifically, one resident with Parkinson's Disease, muscle weakness, unsteadiness, and severe cognitive impairment required substantial to maximum assistance with transfers and used a wheelchair. During an observed transfer, two aides assisted the resident using a gait belt, but one aide placed her arm under the resident's arm and the other held the resident by the waistband of his pants, both of which are not safe transfer techniques. The aides believed they were following their training, although one acknowledged that lifting by the arm felt tight and uncomfortable. Interviews with therapy staff indicated that the correct method for a two-person gait-belt transfer involves one staff member in front and one behind, controlling the transfer from the resident's hips, and specifically avoiding lifting or pulling by the arms or waistband. The physical therapy assistant and physical therapist both stated that hooking under the arms or grabbing the waistband could cause discomfort or injury, and that these methods did not provide adequate control during transfers. The therapy department did not provide specific transfer training to aides but communicated the required level of assistance for each resident. Further observation of a transfer demonstration by two other aides on the Director of Nursing revealed that they also used improper technique by holding the forearms during the transfer. The Director of Nursing confirmed that staff were trained not to pull or tug on residents' arms and acknowledged that such actions could cause skin tears, bruising, or discomfort. The facility's policy emphasized the use of appropriate techniques and devices for safe lifting and movement of residents, but the observed practices did not align with these standards.