Improper Manual Transfer Causes Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer by not following the transfer method recommended by physical therapy and documented in the resident’s plan of care. A resident admitted with a primary diagnosis of disorder of muscle had a care plan initiated on 2/26/26 indicating an ADL self-care performance deficit related to deconditioning, with interventions specifying transfer with a sit-to-stand mechanical lift. As of 3/4/26, the physical therapy assistant stated that nursing staff were expected to transfer this resident using a sit-to-stand mechanical lift with two staff assisting. Therapy had not upgraded the resident’s transfer status to a one-person max assist and expected use of a gait belt for max assist transfers, noting that lifting under the armpits increases risk of injury. The facility’s Lifts and Safe Client Movement Program policy required employees to follow the transfer method indicated in the plan of care. On the date of the incident, two CNAs transferred the resident from a wheelchair to the bed without using the ordered sit-to-stand mechanical lift or a gait belt. One CNA reported that the wheelchair was positioned next to the bed, with the resident’s left leg next to the bed, and that she stood behind the wheelchair and did not touch the resident during the transfer. The other CNA instructed the resident to hold the bed rail with her left hand and then placed her arms under the resident’s armpits to assist her to stand, pivot to the left, and sit on the bed. Immediately after sitting, the resident reported leg pain, and the CNAs observed active bleeding from the left lower leg, which they believed had been scraped on the wheelchair during the transfer. The resident sustained a left lower leg laceration measuring approximately 12–13 cm in length and was transferred to the hospital, where the wound was repaired with 21 sutures.
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