Resident Injured by Unqualified Staff Member During Transfer
Penalty
Summary
A deficiency occurred when a resident with diagnoses including shortness of breath, dementia, and osteoarthritis of the right shoulder sustained two large skin tears on both forearms while being assisted out of a chair to go to the bathroom. The assistance was provided by a Hospitality Aide who was not qualified or permitted to provide direct care to residents. The incident was discovered when an LPN was called to the resident's room and observed the injuries. The resident, who was non-English speaking, communicated through an interpreter that the injuries occurred during the transfer. The LPN documented the incident but did not measure the skin tears at the time. Further investigation revealed that the Hospitality Aide admitted to assisting the resident, which was outside the scope of their job responsibilities as outlined in the facility's job description. The Director of Nursing confirmed that Hospitality Aides are not allowed to provide direct care or assist residents physically. The facility's documentation and staff interviews confirmed that the resident was injured due to the actions of an unqualified staff member, and there was inconsistency in the facility's communication with the resident's representative regarding the incident.