Transfer safety for nursing home residents

When assisting nursing home residents from bed, up from a wheelchair, or to the bathroom, having the appropriate amount of staff and the correct technique can be critical for safety. Many injuries occur every year during transfers and lifts because of lapses in judgement or failure to follow a care plan. On this week’s episode, nursing home abuse attorneys Rob Schenk and Schenk Firm welcome Teresa Boyton to discuss transfer and lift safety in nursing homes.

Schenk: Welcome back to the Nursing Home Abuse Podcast. My name is Rob Schenk.

Smith: And I’m Schenk Firm.

Schenk: Will must be a little forlorn today. But at any rate, we are your hosts for this episode, excited hosts. Before we dive into the meat of the episode, I just want to give a shout-out that, if I’m looking at the – because we record these so far in advance sometimes, but if I’m looking at the calendar correctly, this is National Volunteer Appreciation Week, and why that is important is generally we celebrate the National Long-Term Care Ombudsman Programs during National Volunteer Appreciation Week. So this is a week where you give your long-term care ombudsman a hug and say, “We appreciate you.”

Smith: Yeah.

Schenk: Buy them a cup of coffee.

Smith: The vast majority of them are volunteers if you’re confused.

Schenk: Volunteers, that’s right.

Smith: Some of them are paid and they have paid positions.

Schenk: Some of them are not.

Smith: But the program is made up largely by people who volunteer. Even those that get paid, it’s essentially still volunteer.

Schenk: That’s right. So I just wanted to give a shout-out to those folks. But the real crux of this program is dealing with safety during transfers for nursing home residents, and we’re not doing that alone. We have third time guest appearance for this person. It’s Teresa Boynton.

Smith: Yeah.

Schenk: We first saw her in Episode 86: Caring for nursing home residents at risk of falling. That was way back in September of 2018, then had her here again in Episode 94 in November of 2018 talking about slings and lifts – are they safe? So for those who don’t know Teresa or haven’t watched those episodes or listened to those episodes, can you tell us, Will, a little about Teresa?

Smith: Sure. One of the reasons we like having Teresa on is you hear us talking about these different assessment tools that nursing homes and the healthcare staff have to use, and she’s one of those people that develops those tools. That’s what level of expertise she has. She’s currently an independent consultant. She assists healthcare facilities with implementing and sustaining safe handling mobility and fall prevention programs, and the reason that she’s able to do that is she previously worked for Hill-Rom as clinical consultant and for Banner Health for almost 30 years. And during that time, she developed and validated, and proved that is was useful and true, the bedside mobility assessment tool for nurses, which is also called the BMAT.

She is certified by the Association of Safe Patient Handling Professionals. She’s presented at numerous conferences including a couple years ago the National Fall Prevention Conference and the Greenhouse Long-Term Care Conference on meaningful life and mobility safe lifting practices. This is her third time on the podcast, so we are very honored to have her.

Schenk: Teresa, welcome to the show.

Teresa: Thank you.

Schenk: Great. So Teresa, we love having you on. Again, like I said this at the top of the show before you were on, this is your third appearance and we’ve had you talk about everything from caring for residents that are at risk of falling to exactly what swings and lifts are in other episodes. This one, we’re just talking about safety in resident transfer, and just so we’re not confused, we’re not talking about transferring from one facility to another facility but literally transferring. And I’ll let you give the definition of that. So from a 40,000-foot view, what does transfer mean in a nursing home setting?

What is a transfer of a resident in a nursing home setting?

Teresa: Sure, happy to do that. So basically being able to move the residents from one surface to another, for instance, from bed to recliner, recliner to wheelchair, wheelchair to toilet – so those would all be types of transfers. And then we also look at can they be done independently? Do they need some assistance, partial assistance? Or is this going to be a resident who needs total assistance in moving from one surface to another?

Schenk: Got you. Are there any times, Teresa, when maybe a fall or an accident if more common, like for example, bed to wheelchair, wheelchair to standing or seated to standing? Where do you see in your experience falls and injuries most likely occurring?

When are injuries during transfers most likely to occur?

Teresa: Well one of the things that we know from the Centers for Disease Control, that an elder adult falls every second of every day, so we know it’s extremely common. And then we just have to think about typically, again, many falls, for instance, in a hospital setting are unwitnessed, and I don’t know if that’s been studied quite as much in a residential or care settings, but whenever a resident is moving a greater distant, so having to move from the bed and not just doing a pivot transfer or a seated pivot transfer onto their wheelchair, but they’re having to move from the bed and for a distance to get to, for instance, their recliner, or going from the bed to the toilet. They’re moving a longer distance, so there is a tendency towards, for instance, postural hypertension or static hypertension – they’re at increased risk for a fall.

I also think they’re at increased risk of a fall when the care staff and the resident is not aware that they may now be currently weaker or that their condition has changed somewhat. We know that a lot of falls happen around toileting, that if there’s any urinary incontinence or frequency issues and the resident is anxious to get to the toilet, then that also becomes an increased risk. We also know that with advanced age, so the oldest of the old – 85 years old and above – are at increased risk of falling.

Smith: And Teresa, it’s a phrase that people may not be familiar with even though we’re all familiar with the phenomenon personally. Can you explain what orthostatic hypertension is?

What is orthostatic hypertension?

Teresa: Yeah. It’s a decrease in basically systolic blood pressure and it typically happens within the first minute or three minutes of standing, so the blood pressure drops, making residents or patients lightheaded, feeling weak. So it’s a drop in typically systolic blood pressure.

Smith: Got it. When you stand up and feel dizzy and lightheaded and you want to fall.

Teresa: Correct. Correct. Yup.

Schenk: So Teresa, what are some of the considerations that a nursing home CNA or a nurse would give when assisting a resident from, say, a bed to a wheelchair? What are you looking out for? Where are you putting your hands, that kind of thing?

How are transfers safely performed in nursing homes?

Teresa: Well so you’re looking out for, again, has there been any change in the resident’s status, increased weakness? Is their strength about the same? Are they able to move, pump their ankles, move their knees? Are they able to rise smoothly or do you have to haul them up? And if they’re requiring more than minimal standby contact guard assistance, then that really is when the care staff should be looking at is a mechanical lift a much more appropriate piece of equipment to helping them transfer that resident.

Schenk: I see. When you say a lift, what is a lift?

What is a lift in a nursing home? How are lifts used to transfer residents?

Teresa: So there are a variety of lifts and they’re usually divided into categories, typically called a total lift – that means that the resident doesn’t need to participate at all, that they are dependent and that the lift is going to do all of the work. Typically, they would be in a sling that fully supports them and they’re lifted off of one surface, whether it’s a bed, and then the lift is moved and they’re lowered into a chair, for instance. So that would be a total lift.

There’s also sit-to-stand lifts, a mechanical lift that, again, you use a sling or sometimes it’s called a belt that goes around the resident, and in this case, instead of just lifting them off completely, we’re raising them. They are having the weight there to their legs or their legs are having to support them, although again, based on the type of sit-to-stand lift, they don’t have to participate a great deal, but this would be the patient that for any reason why we can’t get them upright or even partially upright weight-bearing to their legs. So that would be a sit-to-stand lift.

What is a stand aid in a nursing home? How are lifts used to transfer residents?

There are also stand aids, so typically these are non-powered, so they don’t have a battery, they don’t have a power source. The resident has to be able to participate and typically they can pull themselves up and then usually there’s some type of paddle that goes behind them that either supports them or keeps them from falling, kind of this other plate, and that can be used too to transfer.

And each one of those, so for the non-powered stand aid, again, the resident would be able and willing to participate to pull themselves up. They wouldn’t be pushed into it. They would have to participate and pull up. In a sit-to-stand lift, they wouldn’t have to pull themselves up, but the caregiver knows they’re going to be weight bearing to their legs and the lift, the sit-to-stand lift actually helps to get them into that upright position and then can be rolled so they can be transferred, and then again, the first one that I mentioned, the total lift, it can be mobile, meaning it’s on the floor, it moves on the floor, it could be ceiling mounted, overhead mounted, and again, you put a full body sling under them or a sheeted sling under them. It lifts them up and they are just moved, they don’t have to participate at all, over to whatever surface they’re being moved to – a recliner, a toilet, a shower, a bench. So those are kind of the three main types of lifts.

Schenk: Right. And what, going down the line then, I’ve heard the term “a sling,” and the sling is a part of the lift, but can you have a sling apart from a lift?

What is a sling? How are slings used to transfer nursing home residents?

Teresa: Typically the sling is going to be used with a lift, and the lift by itself, the mechanics, the motors go up and down, without a sling, it’s useless. It’s not going to get you what you need to use. If you really are avoiding a manual transfer, in other words using brute force to move a resident, you are going to need a sling. So a sling, again, is going to be attached to, going to be applied onto the resident, and then it’s going to be attached to or applied to a mechanical lift, again, whether that’s a total lift, a sit-to-stand or, again, typically in the case of standing, a sling is not applied usually.

Schenk: What about a transfer board? What is that?

What is a transfer board? How are transfer boards used to transfer nursing home residents?

Teresa: Transfer boards, they’re sometimes called slide boards, but they’re a way of, again, it’s a low tech or there’s no mechanism, there are seated transfer boards or slide boards where the resident would be expected to participate, and so for instance, you might have a slide board – they come in different lengths. It’s typically a smooth wooden board that the resident would help move themselves along from bed they’re seated on, to bed, for instance, to wheelchair. So it’s a way of doing an assisted transfer, but again, the resident would participate.

The other way the transfer board, or sometimes they’re called lateral transfer boards, and that would be used in the case, again, it’s a type of board that reduces friction that allows you to do a supine or a laying down transfer from, for instance, bed to a stretcher, from one horizontal surface to another. In a nursing home setting, long-term care facility, typically a slide board or a transfer board would be for a seated transfer from, for instance, a bed to a wheelchair or from the wheelchair to the toilet. So the resident slides their bottom along it to get from one surface to another.

Smith: Yeah, and if you can imagine, Rob, my mom uses one. She parks the wheelchair next to her bed and then it’s a long, flat board that’s got beveled ends at 45-degree angles.

Teresa: Exactly.

Smith: And it bridges the gap between the bed and the wheelchair so she can start on the wheelchair, go over that bridge into that bed. They’re really effective devices.

Schenk: That’s right.

Smith: Very simple, but extremely effective.

Teresa: They are, exactly. So we’re allowing that resident, that elder person, or again, other folks use them for other reasons, but allowing them to be independent and to do those transfers. They need to be the right length. We do need to be aware of any friction on them. We typically do not want bare skin on a slide board or a transfer board, so there are different ways of kind of handling that, but again, they need to be well fitted, and they have that, as you mentioned, the beveled edges, so you can easily move from one surface to another. And again, they’re great for an active transfer by the resident from, for instance, bed to wheelchair.

When do transfers result in injuries?

Schenk: You mentioned earlier that a great many of the injuries in nursing homes that result from improper transfers occur during toileting. What are the factors that contribute to that? Like why is that more dangerous than going from bed to wheelchair or bed to standing?

Teresa: I don’t know what the research has really definitively shown about that, but I do know that a lot of the falls around toileting are because you’re working in an awkward space. A lot of bathrooms, including in long-term care nursing facilities, are not set up to allow the caregiver to easily help with the transfer. So that’s always a factor, that how much space do you have around the toilet? How do you get through the door to the toilet? And usually again, there’s that sense of urgency, that, “I’ve got to go, I’ve got to go now,” so I think people are moving maybe a little faster than they should be because, again, we want to get you on the toilet so that you don’t have an accident.

Smith: Right.

Teresa: But it’s kind of the environment, that sense of urgency, and I think sometimes it really is a lack of planning, really thinking about, “Okay, this is what we can anticipate, that we are going to have these frequency issues or urgency issues, and we are doing it in an environment, an amount of space that is sometimes isn’t optimal. So how do we plan ahead for that?” And sometimes it’s doing that purposeful rounding or toileting rounds where we get to the residents hopefully before they really have to go and say, “I’m going to take you to the bathroom now,” so it’s done in a much more controlled way. But I think those, the studies show, lead to some of the issues around the toilet. A resident may not want to bother a caregiver, and so if a caregiver asks them, “Do you have to go?” it’s like, “Oh no, you’re busy.” And then again, pretty soon we have that change of urgency, and we get a resident who maybe if they would have gone earlier, we wouldn’t have had the fall. We wouldn’t have had some of the other issues. So toileting is something that all care facilities really have to consider how they’re handling that.

Who determines the amount of help a nursing home resident needs to transfer?

Schenk: I think it’s so important that you mentioned planning, like thinking ahead. If the individual normally goes to the bathroom at 11 p.m., maybe it’s important that somebody be there to do that rather than have that resident try and do it for themselves. But speaking of the planning and understanding how to make a plan, generally who is the individual in the nursing home that is assisting with the transfer, and generally, what type of training do they get in the act of transferring the nursing home resident?

Teresa: That’s a good question and I know it varies throughout the facility. I think some actually get adequate training, so it’s typically going to be your certified nursing aide, your assistant who is actually doing the transfers, and I think they need to be well trained on if they identify, if they feel their resident is weaker than they were in the morning, what do they get to do? So can they default to a safer way of moving that resident? Where maybe in the morning, the resident was able to get up and walk with standby contact guard assist, but now in the afternoon, the aide has identified that they’re looking weaker, they’re stating they don’t feel quite as good, and so is the aide empowered to say, “You know what? I’m going to go get that stand aid or that sit-to-stand lift?” So who is actually assessing that resident on real time using some type of objective finding to identify what is the safest way to do that transfer?

At some facilities, I think it actually worked out those processes and procedures and they do well. An aide can always default to a safer way of transferring versus a more independent or more at risk for a fall if I’m getting the patient up or the resident up and getting them to walk. Or is the aide instructed to let the person in charge of that resident, the nurse know? So it’s having, again, those processes and procedures in place because it is the aides, the nursing home assistants, who are the folks that are sustaining the greatest injuries associated with handling, mobilizing, transferring those residents.

Smith: So what type of – we know that you were highly involved and developed and validated the BMAT. Is the BMAT something that’s used to assess a patient’s transferability or is that different?

How is the BMAT used to asses a nursing home resident’s need level during transfer?

Teresa: No, it absolutely is. So the BMAT, it stands for the Bedside Mobility Assessment Tool, and it was validated in the hospital setting on ICU and med-surg units, but it is being – it does have application with residents in different care, long-term care, assisted living type of facilities. And it’s basically just a way of looking at real time, objective findings – can the resident go through a series of quick physical assessments to – and it’s basically a way, I look at it, of having the resident be aware of – are they aware of any change in their status? And then also allowing that aide or that nurse to look at the resident and see is there a change. So it’s basically seeing can they move to sitting at the edge of the bed and do they need any assistance doing that, or if they’re in the chair, can the sit up independently and maintain their seated balance? So that was the first step of it.

And then if they can do that, can they pump their ankle or move their ankle, straighten out their knee? They don’t have to lift it up high, but can they pump their ankle? One of the other things that the ankle pumping is doing, when we’re talking about orthostatic hypertension or postural hypertension, ankle pumping is one of the ways that can really help with venous return, and that’s one of the things that can be done to potentially help prevent an orthostatic hypertension event. So that’s the second step of the BMAT – can you pump your ankle? Again, we’re getting some better venous return. We’re seeing if that ankle can actually move or is it dropping a little bit? If we have an ankle drop for a variety of reasons, it’s really hard to walk or to stand safely if you cannot move that ankle, if you have that foot drop, the beginning of a foot drop contracture or an actual foot drop contracture, which is in hospitals quite common, even after short terms of bed rest.

The second piece is then can you stand? And again, typically, we want the resident to stand up to a minute. Research shows us that within a minute, up to three minutes, is when the majority of people will start to feel faint, light-headed. You can have them sit back down. So we’re giving some time for the fluid shift to happen, for venous return to happen, to see if things are kind of stabilized or are the barrier receptors going to kick in and, again, prevent us form fainting. So it’s just a cautious approach.

And then the last piece is can you step in place, march in place, then forward step and return, forward step and return? I want you to be able to do that. If you can’t do that, then I should not have you try to walk independently away from your chair or away from your bed to increase the risk of a fall. If you can’t go through that simple series, then for instance, I want to take you from bed to toilet, then I know I need to go get a lift to help you do this because I don’t want you potentially falling and I don’t want to have to support you. So it’s just a quick, little assessment, but again, in doing the assessment, you’re also helping with some of those activities that are connected with looking for and potentially preventing orthostatic hypertension events.

Smith: Right, and just for the family members that may be listening to this episode, when you’re talking about venous return, can you explain you’re talking about blood flow and blood pressure and why that’s important?

How does blood pressure or blood flow affect transferring?

Teresa: Sure. Sure. Typically what happens if we’re lying flat, our fluids tend to shift down into our thorax, so into our chest, our trunk area, when we’re lying flat. And as we move, those fluids need to shift. On the other hand, we also need to make sure that we’re getting the venous blood returning up to our heart so it can be pumped throughout our body, and the biggest skeletal muscle pump that helps with that venous return returning the blood up to our chest, up to our head, is our calf muscles. So by pump your ankle, you’re contracting those calf muscles and that’s helping with venous return. So we want all of our fluids shifting properly so that, again, we get blood to our head and we don’t get lightheaded, to our brain and we don’t get lightheaded.

Schenk: Interesting. Teresa, can you tell us what the Association of Safe Handling Professionals is?

Teresa: Oh yeah, I’d love to tell you about that. So it’s a group of professionals who really are experts and wanting to, through the association, provide education, certification for members. So it’s a great association that is really promoting safe patient handling, safe resident handling and mobility, so really looking at how do we provide resources to people and then, if you’ve been working in the field for a period of time, you, want to become an associate, certified as an associate, we have that membership level. You can also become a clinical – certified as a clinical person or a professional, a P. So we have three different levels.

The association has a lot of great resources on their website, a lot of webinars, trainings for members. They’re very much involved in the annual National Safe Patient Handling and Mobility Conference, which again, not only focuses on acute care setting but also on long-term care settings, assisted living and outpatient ambulatory care. We’re really looking at all the different settings and trying to provide the best, best resources to people in general, but again, to professionals who want to pursue certification.

Schenk: Wow, fantastic. I’m glad we got a plug in. This is a great organization.

Teresa: Yeah, I’m glad I was able to do that too.

Smith: And we’ll put the website up there too. They’re a great website for resources for people who want to find out more about this.

Teresa: Correct.

Schenk: Well Teresa, we really appreciate you coming on the show this week. As always, you are a great resource and I think that our audience truly appreciates it.

Teresa: Oh, thank you very much. I’m happy to do it.

Smith: All right, thank you Teresa, so much. Well it’s always a pleasure having somebody – like I said at the very beginning, she’s one of those professionals that’s so involved in this area that she has created one of the assessment tools. And assessment tools are extremely important in long-term care settings, whether it’s assessing for the likelihood of skin breakdown, the likelihood of falls.

Schenk: It’s like having Samuel Morse on a Morse Code podcast.

Smith: Right, yeah. Yeah, exactly. But yeah, so she’s extremely knowledgeable, always helpful, and that’s a good thing to have on here.

Schenk: So that’s going to complete this particular episode of the Nursing Home Abuse Podcast, and again, be sure to go up to your nearest long-term care ombudsman…

Smith: Or any volunteer of any kind, including fire persons.

Schenk: Fire persons – and give them a big hug, and especially if it’s a fire person, say, “Schenk Firm told me to give you a hug because it’s National Volunteer Appreciation Week as we all know.”

Smith: There are many volunteer fire persons.

Schenk: Correct.

Smith: Most fire persons are volunteer, I think.

Schenk: Is that true?

Smith: I think in a lot of small counties…

Schenk: I know the one down the street, North Highland, they’re volunteer.

Smith: Yeah, they’re all volunteer fire persons – people.

Schenk: Fire people. So you can consume each and every episode as they come out, which is every other week, bi-monthly, on our website, which is NursingHomeAbusePodcast.com, or on our YouTube channel, or you can check us out wherever you get your podcasts from, be it Spotify, Stitcher, Podpuppies, whatever it is.

Smith: Not iTunes.

Schenk: Not iTunes.

Smith: They’re gone.

Schenk: Not iTunes since a year ago. So with that, we’ll see you next time.

Smith: See you next time.