Failure to Provide Required Supervision and Safe Transfer Practices
Penalty
Summary
The facility failed to provide adequate supervision and ensure the use of required assistive devices for two residents, resulting in deficiencies related to accident prevention. One resident, with diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, and polyneuropathy, was assessed as dependent for transfers and required the assistance of two staff members using a sit-to-stand lift with a full body sling. Despite this, two nurse aides transferred the resident from a wheelchair to bed without using the required lift, as confirmed by the resident, her roommate, and facility staff. The resident reported that all three individuals fell to the floor during the transfer, and she experienced back pain as a result. The resident had requested the use of the lift multiple times, but the aides did not comply with her care plan or facility policy. In a separate incident, another resident using an electronic wheelchair exited the building to the front porch for a scheduled break without staff supervision, contrary to the facility's porch supervision schedule. The staff member assigned to monitor the porch was not present, and the resident was left unsupervised until the issue was brought to the attention of facility staff by a surveyor. The resident confirmed that supervision was typically provided by activity staff or aides, but on this occasion, no chaperone was present. These incidents demonstrate lapses in following established safety protocols and supervision requirements for residents at risk of accidents.