Failure to Provide Safe Transfer and Supervision Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents. The resident involved was a bedbound female with severe cognitive impairment, contractures, and multiple comorbidities, including dementia, COPD, and congestive heart failure. She was totally dependent on staff for all activities of daily living and required substantial to total assistance for transfers, with therapy assessments specifying the use of a Hoyer lift for all transfers due to her inability to move or assist herself. Despite these requirements, the resident was transferred by a CNA using a gait belt as a one-person assist, contrary to therapy instructions and the care plan, which specified two-person assistance and the use of a mechanical lift. Following this improper transfer, the resident was found alone in her room with a hematoma on her forehead and a fractured hip. Multiple staff interviews and record reviews confirmed that the resident was unable to move independently and that the transfer method used was not appropriate for her condition. The care plan and therapy notes clearly indicated the need for mechanical lift assistance, and staff were aware of her high risk for falls and injury due to her frailty and cognitive impairment. The incident was not immediately reported, and there was a lack of prompt recognition and response to the resident's injury. Documentation and interviews revealed inconsistencies in staff accounts regarding the events leading up to the injury, and the facility failed to ensure that precautionary interventions and supervision were in place for this known high-risk resident. The failure to follow established care plans and therapy recommendations directly led to the resident sustaining significant injuries while left unsupervised.