Failure to Provide Safe Transfer and Adequate Supervision During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate supervision and assistance during a transfer of a resident with significant cognitive and physical impairments. The resident, a female with diagnoses including non-Alzheimer's dementia, malnutrition, anxiety disorder, depression, and bipolar disorder, required extensive assistance with activities of daily living and was care planned to be transferred with a gait belt and one staff member. During the incident, the CNA attempted to transfer the resident from bed to wheelchair without using a gait belt, as required by facility policy and the resident's care plan. The CNA was observed on video supporting the resident by her head and reaching for a wheelchair that was not within reach, resulting in the resident leaning to the right and hitting her shoulder and neck on the bedrail. The CNA did not ensure the resident was stable before attempting the transfer and did not have the necessary equipment prepared. The incident was not reported by the CNA to the nurse or other facility leadership at the time it occurred. The family member discovered the incident via electronic monitoring and notified the facility, prompting a delayed assessment and x-ray for possible injury. Interviews with facility staff revealed that the CNA had not received training on proper transfer techniques and failed to follow the facility's policy, which mandates the use of a gait belt for all assisted transfers. The nurse and DON were not made aware of the incident until contacted by the family member, and no incident or accident report was completed for the event. The lack of immediate reporting and proper transfer technique placed the resident at risk for injury.