Failure to Supervise Nursing Students During Resident Transfer
Penalty
Summary
The facility failed to provide adequate supervision of nursing students during direct resident care, resulting in an incident where a student nurse, without facility staff present, assisted a resident to the floor during a transfer. The resident, who had end stage renal failure and hypertension and required moderate assistance with activities of daily living, experienced weakened knees during a transfer from chair to bed. The student nurse, unable to support the resident's weight, assisted the resident to a sitting position on the floor. No facility staff were present during this transfer, and the event was only reported to facility staff after the fact by the clinical instructor. Additionally, after being informed by the clinical instructor that the resident had been assisted to the floor, the facility failed to document and assess the resident following the incident. Interviews and record reviews confirmed that the facility's policy and the educational affiliation agreement required nursing students to be supervised by a facility representative during clinical hours, and that all resident care activities by students must be under the supervision of a licensed nurse. These requirements were not followed, leading to the deficiency.