Failure to Ensure Safe Transfers and Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure safe transfer mobility and adequate supervision for residents dependent on staff for transfer assistance, resulting in multiple incidents. One resident with a history of stroke, left-sided weakness, and cognitive impairment was dependent on staff for all transfers. Despite care plan instructions requiring two-person assistance, a registered nurse attempted to transfer the resident alone, during which the resident lost balance and fell from the wheelchair, hitting her head and sustaining a left femoral neck fracture. Family members present at the time reported that the nurse did not respond to their warnings about the resident's inability to move her left leg, and the transfer was performed without proper positioning or assistance, leading to the fall. Another resident with dementia, generalized muscle weakness, and a history of repeated falls was assisted by a CNA during toileting without the use of a gait belt, despite care plan interventions specifying two-person assistance and gait belt use for transfers. This resident was identified as high risk for falls and had a recent history of multiple fall incidents, as well as a visible wound on her forehead from a previous fall. A third resident with vascular dementia and a history of fractures was transferred from a reclining wheelchair to bed using a mechanical lift by two CNAs. During the transfer, the resident was not properly positioned in the sling, with lower extremities unsupported, causing the resident to scream in pain as the sling slid. Additionally, another resident with spinal stenosis and dementia, also at high risk for falls, was transferred from bed to wheelchair using a gait belt but without a non-skid wheelchair pad as required by the care plan. The resident appeared afraid and hesitant during the transfer, and the facility's fall log indicated a history of multiple falls for this resident.