Inadequate Supervision During Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident during a transfer, resulting in injuries that were not immediately reported by staff. The resident, who was moderately impaired cognitively and required substantial assistance for transfers, sustained a head injury when a CNA attempted to transfer her from the bed to a wheelchair. The CNA did not position the wheelchair correctly and let go of the resident, causing her to hit her head on the wheelchair's armrest. The incident was not reported immediately, and the injuries were discovered later by a family member. The resident had a history of dementia and was at risk for falls due to muscle weakness and impaired mobility. Despite being on fall precautions, the CNA did not follow proper transfer procedures and failed to report the incident to the nursing staff. The resident's care plan included interventions to encourage her to ask for assistance during transfers, but these were not effectively implemented. The CNA admitted to not reporting the incident because she did not notice any immediate bruising or injuries. The incident was eventually reported to the Director of Nursing and the physician, who ordered x-rays that showed no fractures. However, the delay in reporting and assessing the resident's injuries highlights a lapse in the facility's protocol for accident and incident reporting. The facility's policy requires all accidents or incidents to be investigated and reported promptly, but this was not adhered to in this case.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by the provider of the terms or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by provisions of the Federal and State laws. **IMMEDIATE CORRECTIVE ACTION:** Staff A was counseled by Director of Nursing and competency was completed regarding safe patient transfers on Resident #1 did not have any negative outcomes related to the alleged deficient practice. Nursing staff was in-serviced by the Director of , with competency completed on safe resident transfers on and. **IDENTIFICATION OF OTHER RESIDENTS HAVING POTENTIAL TO BE AFFECTED:** Any resident requiring assistance with transfers have the potential to be affected by the alleged deficient practice. A facility wide audit was conducted on to identify any residents needing assistance with transfer to ensure that staff are aware and that facility policy is being followed. **SYSTEMATIC CHANGES:** The Assistant Director of Nursing conducted ongoing in-services with nursing staff regarding safe transfers and proper notification of resident's representative and physician. Nursing staff was in-serviced by the Director of , with competency completed on safe resident transfers on and. **MONITORING:** The Director of Nursing/Designee will conduct weekly random observation and competency checks with nursing staff x four weeks, then monthly random observation and competency checks x 3 months to ensure nursing staff are transferring residents safely according to facility policy and procedures. The Director of Nursing/Designee will report findings to the Quality Assurance committee monthly for 3 months to ensure substantial compliance is achieved and maintained.