Failure to Ensure Safe Transfer and Supervision During Resident Outing
Penalty
Summary
A deficiency occurred when facility staff failed to ensure a resident was free from accident hazards and provided with adequate supervision to prevent accidents. The resident, who was a bilateral lower extremity amputee with diagnoses including multiple sclerosis, bipolar disorder, acute kidney failure, and a history of falls, expressed a desire to go boating with a friend. Despite the resident's cognitive intactness, staff assisted him into a boat using a Hoyer lift and secured him to the boat seat with a sheet tied under his arms and behind the seat, as there was no seatbelt available. The resident was unable to remove the sheet himself, and this method of securing was not in accordance with safe transfer or transportation practices. The staff, including LPNs and CNAs, debated the appropriateness of the action and sought authorization from the Operations Manager, who approved the outing over the phone. The staff proceeded to transfer the resident into the boat, which was then driven on a highway to a dock approximately five miles away. During the boating activity, the boat began to fill with water and started sinking, prompting a call for emergency assistance. The resident was ultimately rescued by EMS and returned to the facility without physical injury, but described the experience as traumatic and stated he would not participate in such activities again. Interviews with staff and the resident's friend confirmed that the decision to use a sheet for restraint was made on the spot due to the lack of proper safety equipment, and that the staff's actions were based on the resident's request and the administrator's approval. The facility's policy on safe lifting and movement of residents emphasizes the importance of resident safety, dignity, and appropriate techniques, which were not adhered to in this incident. The event demonstrated a failure to protect the resident from foreseeable accident hazards and to provide adequate supervision and safe transfer methods, as required by federal regulations.