Failure to Ensure Safe Positioning During Meals and Proper Mechanical Lift Transfers
Penalty
Summary
A deficiency was identified when a resident with Parkinson's disease, diaphragmatic hernia, and limited coordination was observed eating lunch while lying in bed with the head of the bed elevated to less than 30 degrees. The resident was positioned low in the bed and slouched forward, and was unable to adjust the bed to a more upright position. The certified nursing assistant (CNA) delivered the lunch tray, confirmed the resident was lying down, and did not offer to reposition the resident to an upright position before leaving the room. The resident ate and drank in this position and began coughing. Both the speech therapist and the director of nursing confirmed that residents should be seated upright while eating to prevent choking and aspiration, and facility policy required proper positioning for meals served in bed. Another deficiency was found when a resident with severe cognitive impairment, contractures, and abnormal posture was transferred from bed to wheelchair using a mechanical lift by only one CNA, despite the care plan and facility policy requiring two-person assistance for such transfers. The CNA stated she had performed single-person transfers before when other staff were busy, acknowledging the risk of falls and injury. Other staff, including another CNA, the staff development department, and the director of nursing, all confirmed that two-person assistance is required for mechanical lift transfers to ensure resident safety. Both deficiencies were supported by direct observation, staff interviews, and review of facility policies and procedures, which clearly outlined the required standards for resident positioning during meals and for mechanical lift transfers. The actions and inactions of staff in these instances did not align with established protocols, resulting in unsafe conditions for the residents involved.