Failure to Investigate Alleged Staff-to-Resident Neglect During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when the facility failed to investigate an allegation of staff-to-resident neglect involving a resident with morbid obesity, diabetes type 2, and congestive heart failure, who was totally dependent on staff for transfers. The resident, who was cognitively intact, reported that during a mechanical lift transfer, a Certified Nursing Assistant (CNA) left him suspended in a sling above a shower chair after becoming upset and leaving the room. The resident was unable to reach the call light and had to call out for help for approximately ten minutes before other staff arrived to complete the transfer. The incident was not documented in the resident's nursing progress notes. Interviews with staff confirmed that the CNA performed the transfer alone, contrary to the care plan requiring two staff members and use of a mechanical lift. After the CNA left the room, two other staff members entered and completed the transfer. The CNA later stated that he routinely performed transfers alone and left the room to de-escalate the situation, while other staff corroborated that the resident was left in the sling and required assistance. Despite these accounts, the incident was not reported to management by the staff who responded, and no incident report was completed. The facility's administrator became aware of the event the following day but did not initiate an investigation, citing the resident's statement that he did not feel neglected or abused. The facility's abuse prevention and reporting policy requires that all incidents or allegations involving abuse, neglect, exploitation, or mistreatment be documented and investigated, regardless of the resident's perception. The lack of documentation and investigation in this case constitutes a failure to respond appropriately to an alleged violation.