Failure to Implement and Follow Neglect Prevention Policies During Resident Transfer
Penalty
Summary
The facility failed to implement and follow written policies and procedures to prohibit and prevent neglect, as well as to investigate allegations of neglect, for a resident with significant cognitive and physical impairments. The resident, a male with advanced dementia, hemiplegia, a history of falls, and multiple comorbidities, required total assistance with transfers using a mechanical lift and two staff members, as documented in his care plan and physician orders. Despite these requirements, a hospice aide transferred the resident without the mechanical lift and without two-person assistance, resulting in a fall that caused a laceration to the forehead and a cervical fracture. The incident occurred when the hospice aide, unable to locate the mechanical lift sling, proceeded to transfer the resident with the help of an LVN, but without the required equipment. After the shower, the aide attempted to transfer the resident back to bed alone, again without the mechanical lift or assistance, during which the resident fell from the bed. The aide admitted to not following the required transfer protocol and not seeking help, despite being aware of the resident's needs. The facility staff, including the LVN and the administrator, were not aware of the improper transfer until after the incident, and the administrator did not initiate an investigation into the cause of the fall as required by the facility's abuse/neglect policy. Additionally, there was a lack of coordination and communication between the facility and hospice staff regarding the resident's care plan and transfer requirements. The hospice care plan did not document the need for a mechanical lift and two-person assistance, and hospice staff were not included in the facility's care plan meetings. The facility's policies required all reports or suspicions of neglect to be investigated, but this was not done in this case. The failure to implement and follow these policies and procedures placed the resident at risk of not receiving necessary care and services.