Failure to Follow Care Plan and Provide Adequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to provide adequate supervision and follow established care plan interventions to prevent avoidable accidents for a resident with a history of falls and complex medical needs. The resident, who required substantial assistance for bed mobility and was dependent on staff for transfers, was observed to have experienced a fall during a transfer from chair to bed. The care plan specified that the resident was to be transferred using a mechanical lift, except when working with therapy, which was trialing slide board transfers. However, nursing staff used a slide board for the transfer without proper training or clearance from therapy, contrary to the care plan instructions. Multiple staff interviews confirmed that the resident was typically transferred with a mechanical lift and that only therapy staff were authorized and trained to use the slide board with the resident. On the day of the incident, two CNAs used a slide board for the transfer after being told by the resident and another CNA that this was now the method used, despite not being trained or cleared for this technique. The resident began to slide during the transfer and was assisted to the floor. The Director of Therapy confirmed that nursing staff had not been trained or cleared to use the slide board for this resident, and the Director of Nursing stated that staff are expected to follow care plan interventions and be adequately trained to reduce the risk of accidents.