Unsafe Transfer Techniques Resulting in Repeated Arm Fractures
Penalty
Summary
The facility failed to ensure safe transfer techniques were used for a cognitively intact resident who required substantial/maximal assistance and two-person help for toileting and incontinence care, resulting in two separate left arm fractures. The resident’s care plan, dated 10/02/25, specified moderate to maximum assistance of two staff for toileting and incontinent care. On 11/30/25, a CMA used a one-person transfer to assist the resident to the bathroom; the resident began to fall and used their left hand to break the fall, after having told the CMA they needed two-person assistance. The resident was subsequently found to have an acute distal left arm fracture on x-ray and was sent to the hospital for stabilization. The CMA later stated they did not know the resident was a two-person transfer. On 01/09/26, two CNAs transferred the same resident to a shower chair by placing their arms under the resident’s arms, rather than using a gait belt or other approved technique. Both CNAs and an LPN reported that during this transfer they heard a pop in the resident’s left shoulder. A mobile x-ray on 01/10/26 showed an acute distal fracture of the left humerus, and the resident was again sent to the hospital for stabilization. The resident later stated they broke their left arm when two aides transferred them under their armpits to get into a shower chair. The DON stated staff were expected to use gait belts and not lift residents under their arms, indicating that the transfer methods used with this resident were inconsistent with facility policy and the resident’s care plan.
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