Failure to Follow Two-Person Transfer Protocol
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in skills necessary to care for resident needs, specifically for a resident requiring two-person assistance with bed mobility and mechanical lift transfers. On one occasion, a Certified Nursing Assistant (CNA) independently turned and positioned the resident and used a mechanical lift for transfer without assistance, contrary to the facility's policy and the resident's care plan. The resident involved had severe cognitive impairment and functional limitations due to Alzheimer's Disease, Cerebral Infarction, and Type 2 Diabetes Mellitus. The care plan and physician's orders specified the need for two-person assistance for transfers, which was not followed by the CNA. This resulted in the resident sustaining a bruise on the forehead, indicating a failure to adhere to the established care plan. Interviews revealed that the CNA did not seek assistance for the transfer, despite the availability of staff, and had a history of similar incidents. The CNA admitted to transferring the resident alone, believing a nurse was nearby, but no assistance was provided. The Director of Nursing confirmed the CNA's actions were against the facility's policy and unsafe for the resident.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 I. The following actions were accomplished for the residents identified in the sample: Resident #73 On 11/18/24, the IDCP Team reviewed the resident’s plan of care related to risk for accidents and determined that the resident continues to require two-person assistance with bed mobility and two-person assistance with a mechanical lift for transfer in and out of bed. CNA #14, who repositioned the resident and completed the mechanical lift transfer without a second staff member providing assistance to complete these tasks was terminated. On 12/30/24, the Chief Nursing Officer met with the Staff Educator to review her responsibility to monitor and ensure that all required CNA annual competencies, including two-person assisting with turning and positioning in bed and mechanical lift transfers are completed by each CNA. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents who require two-person assistance with turning and positioning and/or require the use of a mechanical lift for transfers have been identified as potentially being affected by the same practice. The Staff Educator will identify all CNAs who have not completed competencies related to two-person assistance for turning and positioning in bed and completing a mechanical lift for transfer during 2024. All identified CNAs will have these competencies completed by 01/31/2025. III. The following system changes will be implemented to assure continuing compliance with regulations: The Chief Nursing Officer and Staff Educator will review the facility’s list of annual CNAs competencies and will revise the competency list as needed. Annual competencies will continue to include two-person assistance with turning and positioning/bed mobility and two-person assist mechanical lift transfers. The Staff Educator/designee will schedule and complete annual competency training for all CNAs during 2025 to ensure that all CNAs are able to demonstrate that they are competent to provide care and services as outlined in each resident’s person-centered plan of care. The RN Supervisors and Nurse Managers will continue to monitor for compliance with the Nursing staff following the plan of care during routine and random rounds and observations of care being provided, staff assistance with bed positioning, and transfers being completed with a mechanical lift and two-person assist to ensure the plan of care is being followed and staff demonstrate care practices consistent with facility policy. Immediate corrective actions, such as staff reeducation on bed mobility assistance, transfer/use of a mechanical lift and responsibility to follow the plan of or revision of the plan of care to meet a resident’s care needs based on a change in status. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with all CNAs completing the required CNA competency training annually. The Nurse Manager/designee will complete 5 random unannounced competency observation audits to assess compliance with safe provision of care consistent with the ADL/transfer assist instructions weekly x 4 weeks then monthly x 3 months inclusive of all 3 shifts. Residents requiring two-person assistance with bed mobility and/or two-person assist with a mechanical lift transfer will be included in the audit sample. Auditing will begin early 01/2025. The Staff Educator/designee will review and summarize all observation audits on a weekly then monthly basis as outlined above and will report all findings to the Chief Nursing Officer and Administrator. Corrective actions will be implemented based on summary information. The Staff Educator will report competency audit findings to the QAPI Committee monthly during the 4-month monitoring period for discussion, evaluation, and follow-up corrective action. At the end of the 4-months a decision will be made regarding the need for ongoing auditing and at what frequency. Completion Date: 01/31/2025 Responsibility: Staff Educator