Failure to Provide Adequate Supervision and Safe Transfer Practices Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, resulting in significant injuries to a resident. One resident, who was dependent on staff for all transfers and had diagnoses including multiple sclerosis, lack of coordination, and a prior left tibia fracture, was transferred by a CNA without the use of a gait belt and without proper assistance. This improper transfer from a shower chair to a bed resulted in a fracture to the resident's left tibia. The care plan for this resident did not contain any transfer information prior to the incident, and the required use of a mechanical lift was not documented until after the injury occurred. Despite the first incident, oversight and monitoring of direct care staff were not addressed. The same CNA, who had not received retraining or monitoring after the initial event, again transferred the same resident inappropriately, resulting in a fracture to the right tibia. Interviews revealed that the CNA performed both transfers alone, did not use a gait belt, and was not properly trained or supervised. The resident reported significant pain after both incidents and was not sent to the hospital immediately after the injuries. The facility's policies required two trained staff for mechanical lift transfers and emphasized the need to follow care plans, but these were not followed in practice. Additionally, observations of another resident's transfer revealed further deficiencies in safe transfer practices, including the use of an improperly sized sling, failure to lock beds and wheelchairs, and inconsistent application of manufacturer instructions for mechanical lifts. Staff interviews confirmed uncertainty about proper transfer techniques and equipment sizing. These failures resulted in an Immediate Jeopardy situation, as residents were placed at risk of serious harm and injury due to inadequate supervision, lack of adherence to care plans, and improper use of transfer equipment.
Removal Plan
- In-service nursing staff on where to find the resident's care plan to determine how to care for the resident, with care plan access available on the electronic screen system on each hall and general area.
- Educate nursing team members on the process of transferring residents by using proper body mechanics or using a transfer device for the safety of both residents and staff.
- Complete a skills check-off tool for nursing team members to demonstrate the process of transferring residents using proper body mechanics or a transfer device.
- Remove from duty any nurse not present or in-serviced until in-serviced; monitor and remove from time clock and PCC access until 100% complete or terminated.
- Bring in a Licensed Physical Therapist to educate, complete a skills check-off list, and post-test on transferring a resident.
- PT to educate, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices with DON, ADON D, and ADON E.
- PT to observe DON and ADONs educate, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices with 3 CNAs.
- Only DON, ADONs, and PT will be able to in-service, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices moving forward.
- A resident can only be transferred using a Hoyer lift with a licensed nurse present until the IDT Team decides CNAs are able to complete this transfer without supervision.
- Monitor resident transfers by CNA every shift by DON and ADONs; Administrator to monitor this process daily.
- Test nursing staff on where to find the resident's care plan every shift by DON and ADONs; Administrator to monitor this process daily.
- Hold Ad Hoc QA meeting to discuss causes, in-services, and review interventions.
- Review and address any negative findings in the monitoring and/or auditing system by the QAPI committee for potential systemic change.
- Require all staff to receive in-services concerning safe transfers, accessing resident care plans, and complete hands-on transfer training by the DON or ADONs.
- Require a nurse to be in the room with two CNAs every time a mechanical lift is used, indefinitely, until further notice.
- Ensure all mechanical transfer train-the-trainer sessions, center random skill checks, and instances where transferring is found to be done incorrectly, will be supervised, monitored, and approved by a licensed physical therapist.