Failure to Provide Adequate Supervision and Safe Transfer Techniques
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate transfer techniques for two residents, resulting in increased risk for falls and injuries. One resident with severe cognitive impairment and dementia required supervision or light assistance for transfers. During an observation, two CNAs assisted this resident from a low recliner by placing their forearms under her armpits and lifting her without the use of a gait belt, contrary to facility policy and expectations. Both the physical therapist and nursing home administrator confirmed that a gait belt should always be used for such transfers to ensure safety and prevent injury. Another resident with dementia, Parkinson's disease, and a history of falls experienced multiple unwitnessed falls and incidents of attempting to self-transfer. Documentation revealed repeated episodes where the resident was found on the floor or attempting to get up from a recliner without adequate staff supervision. Alarms intended to alert staff to the resident's movements were not always functional or audible in all areas, and staff were not consistently present or able to respond promptly. Interviews with staff and family members indicated lapses in supervision, with staff sometimes unavailable or not carrying necessary alert devices, and family expressing concerns about the lack of staff presence and responsiveness. Facility policies required the use of gait belts for transfers and outlined interventions for fall prevention, including increased supervision and use of alarms. However, observations and record reviews demonstrated that these policies were not consistently followed. The lack of proper transfer technique and insufficient supervision contributed to repeated falls and near-miss incidents, highlighting failures in implementing established safety protocols for residents at risk of accidents.