Failure to Immediately Report Staff-to-Resident Neglect During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when the facility failed to immediately report an instance of staff-to-resident neglect to the Administrator. The incident involved a resident with morbid obesity, diabetes type 2, congestive heart failure, and limited range of motion in both lower extremities, who was totally dependent on staff for transfers. During a mechanical lift transfer, a Certified Nursing Assistant (CNA) left the resident suspended in a lift sling above a shower chair after becoming upset with the resident, who was expressing concerns about the transfer. The resident was left alone in this position for approximately ten minutes, unable to reach the call light, until two other staff members responded to his calls for help and completed the transfer. The resident was not injured and did not report emotional trauma from the event. The incident was not documented in the resident's nursing progress notes, and the CNA involved admitted to performing the transfer alone, contrary to the care plan requiring two staff members. The CNA stated he left the room to de-escalate the situation after the resident became verbally aggressive. Other staff members who witnessed the aftermath of the incident did not immediately notify management. The Administrator became aware of the event only after being informed by a nurse the following morning, and no incident report was filed because the resident stated he did not feel neglected or abused. The facility's Abuse Prevention and Reporting Policy requires immediate reporting of any incident, allegation, or suspicion of potential abuse or neglect to the Administrator, and timely external reporting to the state surveying agency. In this case, the required internal reporting procedures were not followed, as the incident was not reported immediately to the Administrator, nor was an incident report completed as required by policy.