Failure to Report and Prevent Resident Neglect During Transfer
Penalty
Summary
The facility failed to implement and enforce its written policies and procedures designed to prohibit and prevent abuse and neglect, as evidenced by an incident involving a resident who required extensive assistance with transfers and the use of a gait belt. During an attempted transfer, a CNA did not use a gait belt and left the resident unsupported while reaching for a wheelchair, resulting in the resident falling over and hitting her shoulder and neck on the bedrail. The CNA did not report the incident to the nurse as required by facility policy, and the event was only discovered after the resident’s family member observed it via surveillance footage and notified facility staff. The resident involved had significant cognitive impairment, as indicated by a BIMS score of 00, and multiple diagnoses including non-Alzheimer’s dementia, malnutrition, anxiety disorder, depression, and bipolar disorder. The resident’s care plan specified the need for extensive assistance by one staff member and the use of a gait belt for all transfers. Despite these documented needs, the CNA did not follow the care plan or facility protocols during the transfer, and failed to communicate the incident to nursing staff, which delayed assessment and intervention. Interviews with facility staff, including the LVN, DON, and Administrator, confirmed that the incident was not reported as required. The CNA admitted to not informing the nurse about the resident hitting the bedrail and acknowledged a lack of training on proper transfer techniques. Facility records, including incident and accident reports, did not reflect the event, and the DON and Administrator were unaware of the incident until it was brought to their attention by the family. The facility’s policies required immediate reporting and investigation of such incidents, but these procedures were not followed in this case.