Failure to Assess and Implement Proper Transfer Assistance for Resident with CVA
Penalty
Summary
The facility failed to recognize, assess, and implement appropriate interventions for a resident with a history of cerebrovascular accident (CVA) who required assistance with transfers. The resident's medical record indicated substantial to maximal assistance was needed for transfers due to impairments on one side of her body, and her care plan specified that her feet should be flat on the floor during transfers. However, staff documentation did not consistently reflect the level of assistance required, and there was no analysis of findings in the resident's Care Area Assessments (CAA). During observation, two CNAs transferred the resident using a gait belt and provided total assistance, as the resident was unable to bear weight on either leg and her feet were not flat on the floor, contrary to care plan instructions. Interviews with the CNAs revealed inconsistency in the resident's ability to bear weight, and the administrative nurse confirmed that residents should be able to bear weight during transfers. The facility's policy for activities of daily living (ADLs) was not available for review.