Failure to Conduct Comprehensive Investigation and Ensure Resident Protection After Transfer Injury
Penalty
Summary
The facility failed to conduct a comprehensive and complete investigation, including a root cause analysis, following an incident in which a resident experienced an unsuccessful staff-assisted transfer that resulted in significant injuries. The resident, who had severe cognitive impairment, multiple fractures, and required substantial assistance with transfers, was being transferred by a nursing assistant without the use of a gait belt, contrary to facility expectations and the resident's care plan. During the transfer, the resident tripped and was lowered to the floor by the staff member, resulting in a dislocated and fractured left shoulder and multiple rib fractures. The staff member admitted to not using a gait belt and instead used the resident's clothing to assist with the transfer, a practice she stated was easier due to the resident's size and her own habit, despite having received prior training on proper gait belt use during her certification. The investigation into the incident was incomplete. The facility did not conduct a root cause analysis at the time of the event, and the investigation was limited to interviews with the involved staff member and the resident. No other residents who may have received care from the same staff member were interviewed, and the investigation summary was inconclusive due to insufficient information. The staff member involved was not immediately removed from resident care duties during the investigation and continued to work scheduled shifts, despite the facility's policy requiring reassignment or suspension of employees accused of participating in alleged abuse or neglect during an investigation. Observations following the incident revealed inconsistent and improper use of gait belts by staff during resident transfers. Staff interviews indicated confusion regarding proper transfer techniques, including where to stand during transfers and how to use gait belts correctly. The facility's education and audits following the incident focused on the application of gait belts but did not initially address staff positioning or comprehensive safe transfer practices. The lack of a thorough investigation and failure to provide sufficient protection to other residents during the investigation period constituted the deficiency.