Failure to Provide Adequate Supervision During High-Risk Transfer
Penalty
Summary
A deficiency occurred when a resident at high risk for falls, with a history of cerebral infarction, dementia, depression, hypertensive heart disease, and protein-calorie malnutrition, was transferred using a sit to stand lift by a single CNA, contrary to facility policy requiring two staff members for such transfers. During the transfer from chair to bed, the resident fell forward and struck her head on the machine, resulting in a bleeding injury to her left eyebrow, which was exacerbated by her use of blood thinners. The resident's care plan did not specify any fall precautions, despite her high fall risk status as indicated in her assessment. Interviews with staff confirmed that the CNA performed the transfer alone and that the facility's policy mandates two staff for sit to stand lift operations. The incident was documented in progress notes, and the DON acknowledged that the transfer was not conducted according to policy. The facility's policy, revised in 2008, clearly states that two staff members are required for the use of portable lifts, but this protocol was not followed in this instance.