A resident with Parkinson’s disease, muscle weakness, unsteadiness on feet, and gait/mobility abnormalities had a care plan requiring a stand-pivot transfer with two staff and a gait belt. During an observed toileting transfer, two CNAs assisted the resident, who showed visible shakiness and an unsteady gait, but one CNA placed her hands around the resident’s ribcage to move the resident back to the wheelchair instead of using a gait belt as required. The CNA later acknowledged not using a gait belt, and administrative staff confirmed their expectation that gait belts be used during transfers per the care plan.
A resident with Parkinson’s disease and Alzheimer’s disease, who was non-verbal, non-ambulatory, and unable to self-transfer, had a care plan requiring substantial assistance by two staff and use of a sit-to-stand lift for transfers after 5 p.m. Facility policy also required use of mechanical lifts as a safer alternative and mandated two staff for mechanical lift transfers. Despite these requirements, a CNA did not follow the care plan during a transfer, and the resident was later found with a head lump, facial and hand lacerations, and blood on the floor. An investigation concluded the injuries likely occurred during or shortly after this improper transfer, in which the required lift and two-person assistance were not used.
Improper Sit-to-Stand Lift Transfer: Staff failed to use a sit-to-stand lift according to manufacturer instructions during transfers of a resident with dementia, disc degeneration, and pain. During two observed bed-to-toilet transfers, two CNAs raised the lift while the resident did not bear weight and remained seated in the harness, with the straps pulling into the axillae and raising the shoulders until the resident was lowered onto the toilet. The care plan called for a PAL lift with assist of 2, and admin staff confirmed residents should bear weight when using the lift.
Failure to use safe transfer devices occurred when staff assisted a resident with weakness and unsteady legs during transfers without consistently using the required gait belt. A CNA pulled on the gait belt and the back of the resident’s pants during pivot transfers, and later an RN assisted the resident to stand without a gait belt, using a 4-wheeled rolling walker that rolled away as the resident sat back on the bed.
A resident with weakness, decreased mobility, and a fall risk was transferred by two CNAs without a gait belt or the walker within reach. Staff pulled the resident up by the armpits, then stood and pivoted her into a wheelchair while holding her pants, despite the care plan calling for assist of 2 with a 4WW and the facility policy requiring gait belt use for transfers.
A resident with a history of wandering and identified elopement risk, who was cognitively intact and using a wander guard, followed a visitor out the front door when the door alarm sounded. The receptionist observed the resident leaving and notified a nurse, who then went to the front entrance, but during this delay the resident walked off the premises toward a nearby gas station. A CNA saw the resident walking in the street with a walker and later found the resident inside the gas station purchasing cigarettes, after which the resident was returned to the facility. Facility camera footage confirmed the time the resident left and returned, demonstrating that staff did not provide adequate supervision or timely response to the door alarm to prevent the elopement.
A resident who required hands-on assistance with ambulation was injured when staff failed to provide adequate supervision and support while the resident walked to the bathroom. According to the facility’s fall prevention policy, residents are to receive care based on their individualized fall risk, and the resident reported that CNAs usually held onto them when walking. On the day of the incident, a CNA applied a gait belt and opened the bathroom door but, per the resident’s repeated statements to multiple staff, did not accompany the resident into the bathroom and remained in the bedroom. The resident walked alone, lost balance, and struck their head on the countertop, sustaining a quarter-sized open flap wound to the posterior head with active bleeding. An RN documented the injury and the resident’s condition, and an administrative staff member confirmed the expectation that staff follow the care plan and provide adequate assistance.
Staff failed to assess and utilize the correct sling sizes for two residents during full body mechanical lift transfers, resulting in the use of slings without proper size identification or the use of an incorrect size. Staff relied on a general sizing chart in the supply room rather than individualized assessments, and there was no documentation or education provided regarding appropriate sling selection.
A resident who required a Hoyer lift with two staff for transfers fell during a transfer when a sling loop disengaged from the lift bar after the resident shifted weight. Two CNAs and an LPN were present. The incident resulted in a head laceration requiring staples. Investigation found that the sling strap slid and detached due to the resident's movement and the configuration of the lift bar.
A resident who had recently returned from hospitalization for pneumonia was left unattended in a wheelchair with foot pedals still attached, contrary to facility policy. The CNA responsible did not remove the pedals after being advised by an RN and left the area, during which time the resident attempted to stand and fell, striking their head on a chair. The resident's care plan required assistance with ambulation, which was not provided at the time of the incident.
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