Failure to Provide Supervision and Family Training for Safe Resident Transfer
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for transfers due to right-sided hemiplegia and had documented impairments in both upper and lower extremities, was not provided with adequate supervision or training for safe transfer from a wheelchair to a personal vehicle. The resident's care plan and physical therapy notes indicated she was at risk for falls and required staff assistance for all transfers. Despite this, after a medical appointment, the resident's son was responsible for transferring her into a car and transporting her back to the facility without any education or guidance from facility staff on how to perform the transfer safely. Interviews with facility staff confirmed that there was no policy in place regarding the transportation of residents by family members, and the Director of Rehabilitation stated that no education was provided to the family on safe transfer techniques due to the resident's condition. The lack of supervision and absence of family training for safe transfers created a situation where the resident was at risk for falls and injury during the transfer process.