Failure to Provide Adequate Supervision and Safe Transfer Leading to Resident Injury and Death
Penalty
Summary
A deficiency occurred when the facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for a resident who was on anticoagulant therapy. The resident, who had a history of hemiplegia, morbid obesity, and moderate cognitive impairment, required extensive to total assistance for transfers, with care plan interventions specifying the use of a mechanical lift and two staff for transfers. Despite these requirements, video footage showed a CNA entering the resident's room alone with a mechanical lift, and there was conflicting staff testimony regarding the transfer process. The resident experienced a transfer incident where she slid to the floor, and it was reported that she may have struck her head on a cabinet during repositioning. Following the incident, the resident developed symptoms including nausea, vomiting, headache, and increased weakness. Nursing notes indicated that neurological checks were performed, but there was no immediate escalation or transfer to the hospital until several hours later, despite the resident's ongoing symptoms and her report of head trauma. The resident was eventually transferred to the hospital, where she was found to have an acute on chronic subdural hematoma and subsequently passed away. The autopsy confirmed blunt force trauma to the head as the cause of death, with findings consistent with a fall and significant contusions. Interviews with staff revealed inconsistencies in the accounts of the transfer and the events leading up to the resident's injury. The facility's policies required two-person assistance for mechanical lift transfers and immediate reporting and escalation of suspected head injuries, but these protocols were not followed. The failure to adhere to established safety procedures and to provide adequate supervision and timely medical intervention contributed to the resident's injury and subsequent death.