Complaint Investigation Report

Staff did not properly transfer a resident resulting in an injury. It is alleged that on July 31, 2024, resident (R1) sustained a right hand injury that resulted in an open flesh wound tear of approximately 4 inches, while the resident was transferred from the shower chair to the toilet. According to information obtained, when the wet resident was being transferred out of the bath chair to the toilet, the resident was only assisted by one (1) staff (S1) instead of two staff, and staff (S1) gripped R1's hand in order to prevent the resident from falling. According to information obtained, R1 was assessed as a 2-person assist after a previous incident in March 2024 determined the resident was in need of two staff assistance during bathing and transfers. A total of seven (7) staff were interviewed. Staff (S1) stated that on 7/31/24 at approximately 7 AM, R1 was assisted into the bath by two staff, S1 & S2, but left the room to check on the resident next door, and was not present for assistance out of the bath chair. Staff (S2) stated that S1 screamed for S2's help. R1 had a hand a long and thin skin tear on the right hand. Staff (S1) said that R1's son had instructed staff to transfer the resident out of the bath by holding their hands. Both staff stated they immediately notified former med-tech staff (S8) of the incident and 1st Aid care was provided to the resident. Staff (S1) stated a skin integrity assessment form was completed, it was documented on the end of shift book and shower chart located in R1's room. Wellness Director and Administrator confirmed that former med-tech (S8) did not notify Administrator or Wellness Director, write any chart notes, notify R1's Physician or family, nor mentioned the injury at change of shift. Administrator stated that S8 communicated with PM med-tech former staff (S9) to monitor and change the bandage, but said the tear was minor and 1 cm in length. Staff (S)9 did not check the wound until late at night and discovered the wound needed medical attention. At approximately 10:30 PM, R1 was sent out to the hospital as non-emergency. Based on the picture of the injury, staff agreed the hand injury required a medical assessment by a physician after AM med-tech (S8) assessed the hand injury during the 1st Aid assessment. Therefore, there is sufficient evidence to corroborate the allegation.