Failure to Timely Assist Resident with Transfer Request, Compromising Dignity and Respect
Penalty
Summary
A resident with a history of cerebral infarction and a left hip fracture, who required substantial to maximal assistance for transfers and had intact cognition, requested to be moved from her recliner to her wheelchair. During a continuous observation, the resident made her request to a CNA during a water pass, and the CNA responded that she would assist the resident 'in a little bit.' Despite completing the water pass in the same pod, the CNA did not return to assist the resident and instead engaged in other activities, including speaking with staff and helping another resident with a puzzle. The resident remained in her recliner for over an hour after her initial request, repeatedly expressing her desire to be moved and her frustration at not being listened to. When a nurse entered the room, the resident again requested to be moved, and the nurse stated she would inform the CNA. The CNA eventually returned with the non-mechanical lift but again delayed the transfer, telling the resident she would assist her 'in a little bit.' The resident was finally transferred to her wheelchair more than an hour after her initial request. Interviews with staff confirmed that the resident required an assist of two with a non-mechanical lift and that there was only one such lift available for three pods. Staff acknowledged that the resident should not have had to wait so long for assistance and that, according to facility policy, residents should be treated with dignity and respect, including timely responses to their requests. The Director of Nursing also stated that residents should be moved when they request, regardless of how recently they were transferred.