Failure to Thoroughly Investigate Resident Transfer Incident
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact with a BIMS score of 13 out of 15, reported being transferred from a wheelchair to a bed by a Geriatric Nurse Assistant (GNA) without the use of a Hoyer lift, despite the resident's request for mechanical assistance. The incident was corroborated by another resident's statement, confirming that the transfer was performed manually and not in accordance with the resident's care plan or preferences. The facility's investigation into the incident included obtaining statements from the involved staff, the victim, and witnesses. However, the investigation was incomplete as it did not include interviews with other residents who had been under the care of the alleged perpetrator. The facility substantiated the failure to honor the resident's request for a Hoyer lift but did not fully explore the potential scope of the issue by omitting interviews with additional residents.