Failure to Ensure Use of Non-Slip Footwear During Transfer Resulting in Toe Injury
Penalty
Summary
The deficiency involves staff failure to ensure a resident wore required non-slip footwear during an assisted transfer, contrary to the resident’s care plan and facility policy. The resident had diagnoses including acute kidney failure, epilepsy, and instability of the left knee, and the MDS indicated he was dependent on staff for bed-to-chair transfers and required assistive devices for gait and balance. His care plan for impaired physical mobility directed staff to make sure he wore non-slip shoes or socks. During a transfer from bed to a shower chair, the CNA attempted the transfer while the resident was not wearing non-slip socks or shoes because he was going to the shower. During this transfer, the resident pulled himself up using the transfer pole, became dizzy, and as the CNA adjusted the bed, his leg moved and his toe caught on the floor. The resident later stated that as he was going down the transfer pole, his foot slipped on the linoleum, causing him to slide down, and noted he had no mobility in his left leg. Following the incident, nursing documentation and SBAR notes described a laceration to the plantar aspect of the left 5th toe with a “floppy” toe and no resistance to range of motion, and hospital discharge paperwork confirmed an open toe fracture. The charge nurse, DSD, and DON each stated that the expectation and policy were that residents wear non-slip socks during transfers, and the facility’s safe transfer policy required proper footwear with nonskid soles during transfers.
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