Failure to Provide Safe Transfers and Adequate Supervision
Penalty
Summary
The facility failed to provide safe transfer and adequate supervision for two residents, resulting in accident hazards. In the first incident, a resident who required a two-person assist for bed mobility, as documented in the Minimum Data Set (MDS) and care plan, was being changed by a single Geriatric Nursing Assistant (GNA). During the process, the resident rolled toward the GNA and slid off the bed. The GNA was unable to return the resident to the bed alone and had to call for assistance. The Director of Nursing confirmed that protocol was not followed, as the resident's care plan required two staff members for such assistance. In the second incident, another resident, who was care planned for mechanical lift transfers, was manually transferred from a wheelchair to a bed by a GNA without the use of a Hoyer lift. The resident reported the transfer was rough and that their request for the Hoyer lift was not honored. The GNA admitted to not checking the care plan and transferring the resident manually despite seeing the Hoyer pad. The facility's investigation substantiated the failure to follow the resident's care plan and transfer protocol.