Failure to Safely Transfer Resident Resulting in Fall and Injuries
Penalty
Summary
The facility failed to ensure a safe transfer for a resident during a move from a recliner to a wheelchair, resulting in a fall with injuries. The resident, who had no cognitive impairment and was care planned as needing one-person assistance for transfers with a gait belt, reported that a CNA brought in her wheelchair, locked only one side, and did not apply a gait belt. As she attempted to sit, the unlocked side allowed the wheelchair to flip, causing her to fall onto her left side, sustaining cuts to her elbow and left leg and reporting that she hit her head. The resident stated that staff had not used a gait belt with her prior to this incident, that she was very scared by the fall, and that she now insists on checking that the wheelchair is locked and keeps a gait belt on because she does not trust staff. Staff interviews and documentation corroborated that the wheelchair was not fully secured and that a gait belt was not used during the transfer. The CNA stated she had locked one wheel and was in the process of locking the other when the resident, already standing after having her pants pulled up, turned and sat on the armrest/wheel, causing the chair to tip; the CNA acknowledged not using a gait belt, explaining that the resident frequently refused it. An RN described the same sequence, noting skin tears to the resident’s left elbow and lower leg and that the resident reported hitting her head and having a headache, with neuro checks performed throughout the day. A PTA stated the resident was typically a one-person moderate assist and that staff should always use a gait belt for transfers. The resident’s care plan included instructions for staff to assist with transfers using a gait belt and to instruct the resident to lock wheelchair brakes, and the facility’s fall prevention policy required implementation of appropriate interventions and use of transfer conveyances in accordance with the plan of care, which were not followed during this transfer.
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