Failure to Follow Care-Planned Lift Transfer Resulting in Leg Lacerations
Penalty
Summary
The deficiency involves the facility’s failure to implement required transfer interventions and ensure a safe environment for a resident who was care planned for use of an electronic lift. The resident had multiple diagnoses including heart failure, history of falls, chronic kidney disease, prior stroke, hypertension, hypothyroidism, atrial fibrillation, arthritis, asthma, and left leg pain. An MDS assessment showed the resident had intact cognition (BIMS 15/15), required assistance with all care, and was dependent for transfers. The care plan documented that the resident had a functional ability deficit requiring assistance with self-care and mobility related to weakness, impaired mobility, pain, and poor endurance, and specified that transfers were to be done with a two-assist Invacare electronic lift and large sling. The care plan also identified actual skin integrity impairment, including lacerations/skin tears to both lower extremities, and directed staff to use caution during transfers and bed mobility to prevent striking extremities against hard or sharp surfaces. On the date of the incident, an incident report completed by a nurse indicated that the resident was being transferred from a beauty shop chair to a wheelchair by an OT and a CNA. The nurse documented that she believed the resident was care planned as a two-assist transfer “as needed,” but the resident was actually care planned as a lift transfer at all times. During this manual two-person transfer without the electronic lift, the resident’s leg struck the wheelchair foot pedal, causing three large skin tears on the left leg with significant bleeding. Progress notes described a skin tear to the left lateral upper leg with a skin flap that initially was not approximated, approximately 8 cm in size, and a second open injury of about 10 cm distal to the first, with bleeding difficult to control. The resident was noted to be on Eliquis and aspirin, and pressure dressings were applied before the resident was sent to the emergency department for evaluation. The hospital emergency department report documented an ISTAP type 3 skin tear of the left lower leg with total flap loss, an additional skin tear of the left lower leg, a hematoma of the left lower leg, and current long-term anticoagulation use. Subsequent facility documentation showed ongoing wound treatment orders for the left leg laceration and increased use of PRN narcotic pain medication after the injury. In interviews, the DON confirmed that two staff transferred the resident from the beauty shop chair to the wheelchair and that they were supposed to use an electronic lift per the resident’s plan of care. The administrator stated that the nurse assigned to the resident had told the CNA that the resident could be transferred with a two-person assist without the Invacare lift, and the CNA then obtained help from the OT to perform the transfer, during which the resident’s leg was injured on the wheelchair foot pedal. The facility’s Fall Management policy stated that hazards and resident risk factors would be identified and interventions implemented to minimize falls and related injuries, with a plan of care developed and implemented based on this evaluation.
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