Unsafe Transfer Performed Without Required Equipment and Assistance
Penalty
No penalty information released
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Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident from a wheelchair to bed using only a gait belt and without assistance, despite the resident's care plan requiring a mechanical (hoyer) lift with two staff for all transfers. The resident's transfer status had been updated in May to require the use of a hoyer lift due to declining strength and inability to use a sit-to-stand lift. The CNA, who had recently returned from medical leave, was unaware of the change in the resident's transfer requirements and performed the transfer alone. Interviews with facility staff confirmed that the resident was too weak to be safely transferred by one person with a gait belt.