F0689

D

Failure to Provide Required Two-Person Assist During Transfer Resulting in Skin Tears

Jackson, Michigan Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a safe transfer for a resident, resulting in skin tears to both calves during a transfer back to bed. The resident had been admitted with diagnoses including malnutrition and postprocedural complications of the digestive system and had an abdominal surgical wound. An MDS assessment showed intact cognition. On the date of the incident, the resident reported feeling the backs of her legs pushing against the bedframe while being put back into bed and then feeling pinching, pain, and wetness under her legs, after which bleeding and skin tears were noted on the lateral aspects of both calves. The incident report identified that a mechanical lift (EZ stand) was in use during the transfer and that the resident experienced mild pain in her lower legs after being transferred to the bathroom and back.

Interviews and record review revealed discrepancies and failures related to required transfer assistance. The DON reported that the resident required two-person assistance for transfers with an EZ stand and that a second staff member present in the room at the time of the incident was not assisting with the transfer but gathering supplies. The DON stated it was believed the resident’s loose skin was pinched between the bed frame and the EZ stand. In contrast, CNA F reported transferring the resident by herself, having the resident pivot from the wheelchair back to the bed, and stated that an EZ stand was not used and that she believed the resident was a one-person assist at the time. The resident’s care plan documented the resident as non-ambulatory with transfers requiring two-person assistance using a wheeled walker, and physician orders in effect at the time specified transfers with two-person assistance using an EZ stand.