Non-Compliance in Resident Transfer Procedure
Penalty
Summary
Maplewood Nursing and Rehabilitation was found to be non-compliant with federal and state regulations regarding accident hazards and supervision during an abbreviated survey. The deficiency was identified when a nurse aide, Employee E2, was observed transferring a resident, who was totally dependent on assistance for transfers, using a mechanical lift without the required second staff member present. The facility's policy mandates that two staff members are necessary to safely operate the mechanical lift, ensuring one controls the lift and the other assists with the resident. However, during the transfer, Employee E2 was left alone as the second staff member, Employee E3, left to attend to another resident. The resident involved, admitted in 2016, had multiple diagnoses including atrophy, dysphasia, dementia, and malnutrition, and was assessed as needing a mechanical lift for transfers. Despite the facility's inservice training on proper mechanical lift usage, which both Employee E2 and Employee E3 attended, the policy was not adhered to during the incident. Employee E2 acknowledged awareness of the two-person requirement, and Employee E3 confirmed that leaving a single staff member to perform the transfer was against policy.
Plan Of Correction
Immediate Corrective Action: Employee 2 was re-educated and counseled regarding the policy. House wide corrective action: Current CNA's will have lift competencies completed. Education: Licensed nursing staff will be re-educated on the facility's policy regarding use of the mechanical lift. Performance Monitoring: DON or designee will complete 10 random observations weekly x 4 weeks to ensure staff are using the mechanical lift per facility policy. The results of the audits will be reviewed during the facilities monthly QAPI meeting. The QA committee will determine the need for continued monthly auditing.