Failure to Provide Adequate Supervision and Assistance During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a hospice aide failed to use a mechanical lift and two-person assistance to transfer a resident with significant mobility and cognitive impairments, resulting in a fall. The resident, a male with diagnoses including advanced dementia, cerebral infarction, hemiplegia, contractures, and a history of falls, required total assistance for transfers as documented in his care plan and physician orders. Despite these requirements, the hospice aide attempted to transfer the resident without the mechanical lift and without a second person, leading to the resident falling and sustaining a 2 cm laceration to the forehead and a cervical spine fracture. The incident took place during a transfer from a shower chair to the bed after bathing. The hospice aide did not request assistance from facility staff, even though staff were available and had previously instructed her to seek help for all transfers. The aide later stated she was aware of the need for a mechanical lift and two-person assist but did not use the lift because she could not find the sling and sometimes performed transfers alone when help was unavailable. There was also confusion and lack of coordination between the hospice and facility care plans, with the hospice care plan not specifying the need for a mechanical lift and two-person assist, while the facility care plan and physician orders did. Interviews revealed that the hospice aide and facility staff had inconsistent understandings of the transfer requirements, and the hospice aide admitted to not always following the prescribed procedures. The facility did not have a fall prevention policy in place at the time of the incident, and there was no established process for sharing or coordinating care plans between the facility and hospice staff. The lack of communication and adherence to established transfer protocols directly contributed to the resident's fall and subsequent injuries.