Failure to Provide Required Two-Person Assist During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including Parkinson's Disease, Anxiety, and Vascular Dementia, did not receive the required level of assistance during a transfer. The resident's care plan, updated several months prior, specified that a total body lift with the assistance of two staff members was necessary for all transfers. However, on the day of the incident, a Certified Nurse Aide (CNA) transferred the resident alone using a sit-to-stand lift, contrary to the care plan instructions. During this transfer, the sling rubbed against the resident's arm, resulting in two skin tears and a 1 cm by 1 cm abrasion to the head. The CNA later admitted to being aware of the two-person assist requirement but did not seek assistance or check the CNA instructions prior to the transfer. Interviews with facility staff confirmed that the resident's transfer status had not changed and that the care plan and CNA instructions clearly documented the need for two-person assistance. The CNA had previously provided two-person assistance to the resident on earlier dates, as documented in facility records. The incident was discovered when a nurse observed the injuries and questioned the CNA, who then acknowledged transferring the resident without help. The lack of adherence to the care plan and failure to provide adequate supervision and assistance directly led to the resident sustaining injuries during the transfer.