Failure to Investigate and Prevent Neglect During Resident Transfer
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated, specifically in the case of a male resident with significant cognitive and physical impairments. The resident, who had diagnoses including advanced dementia, cerebral infarction, hemiplegia, and a history of falls, 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 adequate 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 sling for the mechanical lift, proceeded with the transfer with only one staff member and without the required equipment. The aide admitted to not always using the mechanical lift and sometimes transferring the resident alone due to lack of available help. Facility staff, including the LVN, were aware of the resident's care needs but did not ensure the proper transfer method was used. The event was not immediately or thoroughly investigated by the facility administration, and the administrator was unaware of the improper transfer until informed by hospice staff days later. There was no evidence that the facility initiated an investigation into the cause of the fall or monitored adherence to care plan interventions for transfers. Additionally, there was a lack of coordination and communication between the facility and hospice staff regarding the resident's care plan. Hospice staff did not have the updated care plan reflecting the need for a mechanical lift and two-person assistance, and they did not participate in the facility's interdisciplinary care plan meetings. The facility's policy required all reports or suspicions of abuse or neglect to be investigated, but this protocol was not followed in this case, as the administrator did not begin an investigation or ensure protective measures were in place during the process.