Failure to Assist Dependent Resident with Out-of-Bed Transfers
Penalty
Summary
Staff failed to provide necessary assistance to a resident with severe physical and cognitive impairments, resulting in the resident not being assisted out of bed as required by their care plan. The resident, who had a history of cerebral infarction with hemiplegia/hemiparesis, diabetes, intracardiac thrombosis, peripheral vascular disease, hypertensive heart disease, chronic atrial fibrillation, vitreous degeneration, and aphasia, was assessed as being dependent on staff for all activities of daily living, including transfers and mobility. The care plan specified that the resident should be encouraged to be out of bed using a mechanical lift and with the assistance of two staff members for transfers to a tilt-in-space wheelchair. Despite these documented needs and interventions, multiple observations over several days revealed that the resident remained in bed and was not assisted into their wheelchair. Interviews with nursing and therapy staff confirmed that the resident had not been assisted out of bed since discharge from skilled therapy services, and there was no medical reason preventing the resident from being mobilized. The facility's policy required staff to provide assistance with activities of daily living, including transfers, for residents unable to perform these tasks independently, but this was not followed in the resident's case.