Failure to Ensure Safe Transfer Practices and Adequate Supervision
Penalty
Summary
The facility failed to provide safe transfer practices for two residents, resulting in deficiencies related to accident hazards and inadequate supervision. One resident with hemiplegia, left foot drop, and cognitive intactness was transferred by a CNA without the use of a gait belt and without a second staff member, despite care plan requirements. The CNA was also using earbuds and talking on the phone during the transfer, which led to the resident sustaining a skin tear on her left lower leg. The incident was not documented in the nurse's progress note, and the care plan was not updated to reflect the injury or provide interventions for the skin tear. Another resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, required two-person assistance and a mechanical lift for transfers. On the day of the incident, two CNAs used the wrong sling configuration during a transfer, placing the long ends of the sling at the resident's head instead of crossing them between the legs. This improper use of equipment created a risk of the resident falling from the lift. The resident was also left sitting in a wheelchair for nearly three hours, resulting in significant skin breakdown and complaints of pain, as staff were unable to meet resident needs promptly due to low staffing levels. Facility policy mandates the use of a gait belt for all physical transfers and requires a mechanical lift for residents needing two-person assistance. Staff interviews confirmed that these policies were not followed, and that care plans were not reviewed or updated as required. The failures in following transfer protocols and providing timely care directly contributed to the residents' injuries and discomfort.