Failure to Provide Adequate Supervision and Assistive Devices During Resident Transfers
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, as evidenced by multiple incidents involving four residents. One resident, who had a history of fractures, repeated falls, osteoporosis, and mild cognitive impairment, required substantial to maximal assistance for transfers according to her care plan and therapy evaluation. However, during a sit-to-stand transfer, the assigned CNA did not provide contact guard assistance or use a gait belt, instead standing by and holding the wheelchair while the resident attempted to transfer herself. This resulted in the resident falling headfirst into a wall, causing multiple rib fractures, a cervical vertebra fracture, a compression fracture, and a scalp laceration. Other residents also experienced deficiencies in supervision and use of assistive devices. One resident, with a history of osteoporosis, muscle weakness, and falls, reported bruising on her arm from contact with an exposed metal nut on the stand aid device, which was missing its protective plastic cap. Staff interviews revealed that the issue had been verbally reported to a nurse, but no maintenance request had been made, and maintenance staff were not routinely checking for missing caps. Another resident, who was hemiplegic and at high risk for falls, reported that staff often did not use a gait belt during transfers and sometimes pulled on his clothing instead. Observations confirmed that staff did not always use gait belts as required by policy and care plans. Additionally, a resident with arthritis, cataracts, and legal blindness was observed being transferred with a stand aid without a gait belt and while wearing non-slip-resistant socks. The CNA involved admitted to forgetting the gait belt and recognized the risk of falls without proper equipment. Review of facility policies indicated that staff were expected to use gait belts and follow individualized care plans for transfers, but these protocols were not consistently followed, leading to actual harm and the identification of Immediate Jeopardy.