Failure to Ensure Safe Transfers and Adequate Supervision Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident with significant cognitive and physical impairments received adequate supervision and the correct use of assistive devices to prevent accidents. The resident, who was nonverbal, dependent for all activities of daily living, and had diagnoses including Alzheimer's disease and diabetes, required assistance from two staff members for transfers. Despite this, staff used inconsistent transfer methods, including sit-to-stand lifts and gait belts, and there was confusion among staff regarding the resident's correct transfer status. The care plan was not updated to reflect the resident's need for a Hoyer lift with two staff until after the resident sustained a tibia fracture. Multiple staff members were unaware of the proper transfer method, and the resident's transfer status was communicated inconsistently, often via whiteboards or report sheets, leading to further confusion. On one occasion, the resident was found with a large, painful bruise on her right lower leg, which was later diagnosed as a nondisplaced acute proximal tibia fracture. Staff interviews and documentation indicated that the injury likely occurred during a transfer, but no staff could identify the specific incident. The facility's investigation was unable to determine the exact cause of the injury, but it was noted that staff had been using various transfer methods and that the resident's room configuration may have contributed to the risk of injury. The investigation also revealed that the sit-to-stand lift was not indicated in the resident's care plan at the time of the injury. A subsequent incident involved the resident sliding out of a Hoyer lift sling during a transfer, resulting in a fall onto her back and shoulders. The investigation found that the sling used was too small and did not provide adequate support due to the resident's rigidity. Not all staff were educated on the proper use of the Hoyer lift or the correct sling size, and observations showed improper transfer technique, with the resident's body not properly supported and her legs and face in incorrect positions during the lift. Staff interviews confirmed inconsistent training and a lack of clear protocols for determining sling size and transfer methods, contributing to repeated failures in providing safe and adequate supervision during transfers.