Failure to Follow Assessed Transfer Status and Use Required Lift During Shower Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed a resident’s assessed transfer status, which required the use of a mechanical lift for transfers. The resident had diagnoses including a prior right femur fracture and had a BIMS score of 5, indicating moderate cognitive deficits. The MDS documented that the resident required maximum to dependent assistance with ADLs, transfers, and bed mobility, and the care plan specified that the resident had limited ability to transfer and required a mechanical lift, being dependent on staff for transfers. On the day of the incident, a CNA assigned to the resident for the evening shift wheeled the resident into the shower room in a wheelchair and independently transferred the resident from the wheelchair to the shower chair without a gait belt, assistive device, or staff assistance. After the shower, the CNA placed a towel or bath blanket on the shower floor to keep a foot dressing dry, then asked the resident to stand and hold the rail so she could transfer the resident back to the wheelchair. When the resident stood, her foot slipped and she tripped on the shower chair footrest; the CNA reported catching the resident and then lowering her to the floor as the resident yelled about leg pain. The LPN responding to the incident found the resident on the shower floor, wet and in a gown, with the right leg appearing more contracted than usual and the resident complaining of right knee/leg pain on range of motion. The resident was sent to the local hospital, where imaging showed an angulated, foreshortened fracture of the distal right femoral shaft distal to existing right femoral hardware. The resident later recalled losing her balance and that the CNA could not catch her. The DON stated that the resident’s transfer status at the time required one-person assistance with a pivot transfer and that residents requiring one-person assistance should be transferred using a gait belt, while residents needing two-person assistance should be transferred using a gait belt and mechanical lift. The facility’s Safe Lifting and Movement of Residents policy required mechanical lifting devices for any resident needing two-person assistance and prohibited manual lifting except in emergencies, and the CNA job description required that all transfers and lifts be performed safely and according to facility policy. Staff interviews and record review showed that the resident’s assessed and care-planned need for mechanical lift assistance was not followed during the shower transfer, resulting in the fall and subsequent femur fracture.
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