Failure to Follow Transfer Requirements and Verify Wheelchair Brakes Resulting in Fall Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer for a resident who required two-person assistance and a mechanical lift, resulting in a fall with injury. The resident had vascular dementia without behavioral disturbances, muscle weakness, anxiety disorder, and a BIMS score of 6/15, indicating poor short- and long-term memory. A physician’s order dated 10/28/25 and the resident’s care plan dated 11/13/25 specified that the resident required a mechanical lift and assistance of two staff for all transfers due to generalized weakness, vascular dementia, and forgetfulness. The quarterly MDS documented that the resident was dependent on staff for bed mobility and transfers. On 12/12/25, a nurse aide (NA #1) who did not consistently care for this resident relied on an assignment sheet that incorrectly indicated the resident was an assist of one for transfers. NA #1 did not review the resident care card, was not sure what a resident care card was or where it was located, and was unaware that transfer status on the care card, not the assignment sheet, should be followed. NA #1 positioned the wheelchair at the right side of the bed, sat the resident at the edge of the bed, applied a gait belt, and attempted a manual pivot transfer without obtaining a second staff member or using a mechanical lift, contrary to the physician’s order and care plan. During the transfer, NA #1 noted the resident was much weaker and heavier than expected but did not sit the resident back on the bed or request assistance. Instead, he bear hugged the resident and pivoted with difficulty, resulting in the resident being only partially seated at the edge of the wheelchair. Although NA #1 reported that he applied the wheelchair brakes, he did not move or jiggle the wheelchair to ensure the locks were fully engaged. The wheelchair began to roll backward, and the resident fell forward to the floor, striking the face and sustaining a bloody nose, a skin tear to the bridge of the nose, and a nasal laceration that required sutures in the emergency department. The facility’s wheelchair policy required positioning the wheelchair appropriately, applying brakes to lock the wheels, and using proper transfer techniques with a gait belt, which were not fully followed during this transfer.
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