Failure to Provide Required Two-Person Assistance During Transfer Resulting in Laceration
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance during a transfer, resulting in a laceration that required sutures for one resident. The resident had diagnoses including cellulitis and muscle weakness, and the MDS dated 1/11/26 documented that the resident required dependent assistance from two or more helpers for chair/bed-to-chair transfers. On 2/5/26, while being transferred from a wheelchair to bed, the resident’s left leg struck or was dragged along the edge of the bed, causing a laceration to the left lateral lower leg. An on-call physician note documented a 6 cm by 0.5 cm by 0.25 cm laceration with some earlier bleeding, and a nursing progress note later that day described a 6 cm by 0.5 cm by 0.0 cm laceration, with the resident stating that their leg was dragged on the side of the bed during the transfer. Staff documentation and interviews showed that the transfer was performed by a single CNA without another employee assisting, despite the resident’s documented need for two-person assistance for transfers. The CNA confirmed via phone statement that they transferred the resident from the wheelchair to the bed without another employee. At the time of the incident, the resident’s care plan did not yet include the requirement for two-person assistance with all transfers; this intervention was not initiated in the care plan until the day after the incident. During an interview, the Nursing Home Administrator and the DON confirmed that the facility failed to provide adequate supervision to prevent the injury that resulted in the laceration requiring sutures.
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