Unsafe Shower Transfer Without Required Two-Person Mechanical Lift Assist
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer practices and adequate supervision during a shower transfer for one resident, resulting in a left humerus fracture. The facility’s Safe Resident Handling/Transfer policy stated that residents were to be handled and transferred safely to prevent or minimize risk of injury and to provide a safe, secure, and comfortable experience. The quarterly MDS for the resident documented a BIMS score of 15, indicating little to no cognitive impairment, and noted that chair-to-bed-to-chair and tub/shower transfers were not attempted due to medical or safety concerns. The resident’s active diagnoses included dementia, muscle weakness, congestive heart failure, osteoarthritis, and hypertension. Progress notes dated two days after the incident documented bruising under the resident’s left axilla with reported tenderness, and an X-ray confirmed a fracture of the proximal left humerus. The facility incident report stated that the resident complained of left shoulder pain after a transfer to a shower chair, with bruising noted under the left axilla and left arm. CNA LL acknowledged that the resident required a mechanical lift with two staff for transfers but reported that, when all mechanical lift pads were in use and the resident insisted on a shower, she transferred the resident without assistance, while another CNA only held the shower chair and did not physically assist with the transfer. CNA MM confirmed that she held the shower chair while CNA LL physically lifted the resident under the arms without using the mechanical lift, despite the resident’s requirement for a two-person mechanical lift transfer. The Administrator and the National Director of Risk Management both confirmed that the resident was a two-person assist for transfers using a mechanical lift and that there should have been a second CNA assisting with the transfer.
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