Failure to Provide Adequate Supervision and Safe Transfer Practices
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of multiple fractures, osteoporosis, and total dependence on staff for mobility and self-care was not provided adequate supervision and assistive devices to prevent accidents. The resident's care plan required a two-person assist for transfers using a sit-to-stand mechanical lift. On the day of the incident, a medication aide (MA) who was filling in for the usual CNA performed a transfer using the sit-to-stand lift without a second staff member present, contrary to facility policy and the resident's care plan. During the transfer, the resident complained of pain, but the MA did not notify the nurse before proceeding with the transfer. The nurse was only informed of the pain after the transfer was completed. Subsequent assessment and imaging revealed the resident had sustained an acute spiral fracture of the left femur. Interviews with staff confirmed that mechanical lift transfers were to be performed with two staff members and that any complaints of pain prior to care required immediate nurse notification for assessment. The facility's policy on mechanical lifts explicitly required two staff for all transfers and an assessment of the resident's condition before use. The MA acknowledged being aware of these requirements but proceeded alone due to lack of available assistance. The nurse and other staff confirmed that the resident was dependent for all mobility and that no incidents or changes in condition were reported prior to the injury. The event was identified as past non-compliance, with the Immediate Jeopardy period beginning and ending before the state's investigation.