Failure to Provide Adequate Supervision and Assistive Devices During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and a history of falls received adequate supervision and assistive devices to prevent accidents. The resident, who is dependent on staff for transfers and has dementia, was observed being transferred from a wheelchair to bed without wearing non-slip footwear, contrary to facility policy and the resident's care plan. Additionally, the resident did not have a scoop mattress as documented in the care plan for fall prevention. During the transfer, staff used a mechanical sit-to-stand lift, but it was noted that the resident's transfer method had been inconsistently applied, with some staff using a gait belt and assist of two instead of the required mechanical lift. Interviews with staff revealed confusion and inconsistency regarding the resident's transfer status and required interventions. The CNA assigned to the resident reported using a gait belt and assist of two, while the LPN and ADON indicated the use of a mechanical sit-to-stand lift was required. The DON confirmed that changes to a resident's transfer status should involve therapy, but no therapy evaluation was found in the resident's record. The resident's Kardex and care plan both indicated the need for a sit-to-stand lift and a scoop mattress, but these interventions were not consistently implemented at the time of the survey.