Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Serious Resident Injury
Penalty
Summary
A deficiency occurred when a resident with significant medical complexities, including dementia, Parkinsonism, a history of falls, and recent fractures, was not provided adequate supervision and assistance during a transfer. The resident was care planned as a high fall risk and required total assistance of two staff members with a mechanical lift for all transfers. Despite this, only one certified nursing assistant (CNA) was present in the room while preparing to transfer the resident from a wheelchair to the bed. The CNA was waiting for a second staff member but remained alone with the resident, who exhibited involuntary jerky movements associated with Parkinson's disease. During this period of inadequate supervision, the resident experienced a sudden movement and fell face down onto the floor, resulting in multiple serious injuries, including facial and skull fractures, a possible cervical spine fracture, and extensive bruising. Interviews with staff and other residents confirmed that the transfer was attempted without the required two-person assistance, and the facility's policy explicitly stated that two staff members must be present for mechanical lift transfers. The incident was witnessed by staff responding to the fall, and the resident was found on the floor with significant bleeding and injuries. The resident's medical records and care plan documented his high risk for falls and need for two-person assistance due to his physical and cognitive impairments. Staff interviews revealed that the CNA was aware of the requirement for two-person transfers but proceeded to prepare the resident alone while waiting for help. The lack of immediate supervision and failure to follow established transfer protocols directly led to the resident's fall and subsequent injuries.