Improper Repositioning Technique Causing Forearm Injury and Unaddressed Pain Complaint
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper repositioning and safe transfer techniques for a dependent resident who required assistance of two staff for activities of daily living. The resident, who had moderately impaired cognition with a BIMS score of 11 and a diagnosis including unspecified pain, was observed on multiple occasions with a bandage and dark purple bruising on the right forearm. The resident reported that a CNA and an LPN attempted to pull them up in bed, with the CNA leaning over and pushing down on the resident’s arm while moving them up in bed. The resident stated they hollered and told staff their arm was hurting, but the staff continued to move them. Staff interviews confirmed that the resident had just returned from the emergency room when the LPN and CNA assisted them to bed and moved them up in bed. The LPN stated the CNA reached over the resident and grabbed the draw sheet from both sides while the LPN placed an arm under the resident’s knees to move the resident up, and acknowledged hearing the resident say, “Ow my arm,” but assumed it was related to chronic arm pain. The CNA described the same technique and acknowledged that it was not the correct method, stating that one person should have been on each side of the bed using the draw sheet. Other CNAs, an LPN, and a restorative aide described the correct procedure as having one staff member on each side of the bed and using a draw sheet or pad to move a resident up, and nursing staff described that a complaint of pain should prompt assessment and repositioning, with further actions and documentation if pain persisted.
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