Failure to Provide Adequate Supervision and Assistance During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident who required extensive assistance from two staff members for transfers. The resident, a female with severe cognitive impairment, multiple physical and neurological diagnoses, and limited mobility, was transferred by a single CNA instead of the required two-person assist. During the transfer from her wheelchair to her bed, the CNA lifted the resident alone, resulting in the resident's head bumping against the wall. The CNA admitted to performing the transfer alone, despite the care plan specifying the need for two staff, and stated that he had done so in the past. The incident was witnessed by the resident's roommate, who reported being awakened by the sound of the resident's head hitting the wall. The CNA immediately reported the incident to the unit manager and nurse, who assessed the resident and found a small raised area on the back of her head but no bleeding or discoloration. The resident's vital signs and mentation were at baseline, and she did not display signs of pain or distress during the assessment. The facility's policy and care plan documentation confirmed that the resident required a two-person assist for transfers, and this information was available in the resident's chart and point of care system. Interviews with staff, including the CNA, nurses, unit manager, and director of nursing, confirmed that the transfer was not performed according to the resident's care plan and facility policy. The CNA acknowledged not following the required procedure and indicated that he had previously transferred the resident alone. The facility's transfer and lift policy emphasized the importance of individualized care plans and appropriate staff assistance to ensure resident safety during transfers, which was not adhered to in this case.