Unsafe Resident Transfer Techniques and Failure to Follow Safe Handling Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were handled safely during transfers in accordance with its Safe Resident Handling/Transfers policy, which requires safe transfer techniques and use of gait belts or lifts as needed. For one resident with acute posthemorrhagic anemia and COPD, surveyors observed two CNAs transferring her from wheelchair to bed by one CNA standing behind the wheelchair and sliding her arms under the resident’s armpits while the other CNA placed her arms under the resident’s legs, lifting her out of the wheelchair and placing her in bed. When questioned, one CNA stated the resident was care planned to be transferred in this manner. The Director of Rehabilitation later explained that the proper “bear hug” transfer is for a resident who can assist with a one-person transfer and requires a gait belt around the resident’s waist, and that grabbing a resident under the arms and legs is not appropriate. The DON also stated the CNAs should not have transferred the resident by grabbing her under the arms and legs. The deficiency also includes an incident involving another resident admitted with pneumonia, UTI, and CHF, whose care plan required two staff for transfers. A physical therapy evaluation documented the resident needed partial/moderate assist for chair/bed-to-chair transfers, and a subsequent MDS documented the resident was dependent for such transfers, requiring the assistance of two or more helpers. Despite this, an incident report and staff statements showed that one CNA performed a bear hug transfer from wheelchair to bed while another CNA stood behind and did not actively assist. The CNA performing the transfer reported not remembering using a gait belt, while the other CNA stated a gait belt was present but too loose, and the resident landed perpendicular on the bed after the transfer. The DON stated that the CNA used the bear hug technique, was hurrying, and should have slowed down and waited for the second CNA to assist.
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