Failure to Provide Required Two-Person Assistance During Resident Transfer
Penalty
Summary
A deficiency occurred when facility staff failed to provide the required two-person assistance during a transfer for a resident with severely impaired cognition and total dependence on staff for activities of daily living (ADLs). The resident's medical record and MDS assessment indicated a need for two or more staff members and the use of a Hoyer lift for all transfers. Despite this, a CNA attempted to transfer the resident alone from a shower bed to the resident's bed after waiting approximately 30 minutes for assistance, resulting in an assisted fall and an abrasion to the resident's left upper back. The CNA acknowledged awareness of the resident's transfer requirements but proceeded without the necessary help. Interviews with facility staff, including the DSD and DON, confirmed that the CNA did not wait for the second staff member or the Hoyer lift as required by the resident's care plan. The DSD observed the CNA with the resident and instructed another staff member to bring the Hoyer lift, but the transfer was attempted before assistance arrived. The DON verified that the resident sustained a fall during the transfer and that the CNA should have waited for the required assistance.