Failure to Ensure Competency in Safe Resident Transfers
Penalty
Summary
Nurse aides at the facility failed to demonstrate competency in safe transfer techniques for residents requiring assistance, as evidenced by observations and interviews. In one instance, two aides assisted a male resident with Parkinson's Disease, muscle weakness, and severe cognitive impairment in transferring from a recliner to a wheelchair. During the transfer, one aide placed her arm under the resident's arm while the other held the resident's pants by the waistband, contrary to safe transfer protocols. Both aides believed their methods were correct, though one acknowledged that being lifted by the arm could feel tight and uncomfortable. The resident's care plan indicated the need for substantial to maximum assistance with transfers, and the use of a gait belt was observed, but the techniques used did not align with best practices as described by therapy staff. Further review included a demonstration by two other aides who performed a two-person gait-belt transfer on the Director of Nursing (DON). During this demonstration, both aides held the gait belt in the back and assisted the DON to stand by holding the forearm, also deviating from recommended techniques. The DON confirmed that aides were instructed not to pull or tug on residents' arms and acknowledged that improper techniques, such as hooking under the arm or grabbing the waistband, could cause discomfort, skin tears, or bruising. The DON stated that staff were trained on transfers and that a skills fair was conducted for competency checks, but ongoing monitoring of transfer techniques was not performed. Interviews with therapy staff indicated that aides were not specifically trained by therapy on transfer techniques, though they were informed about the level of assistance required for each resident. The facility's policy emphasized the use of appropriate techniques and devices to ensure resident safety and comfort during transfers. However, the observed practices and staff interviews revealed inconsistencies between training, policy, and actual transfer methods used by aides, resulting in a failure to ensure staff competency in safe resident transfers.