Unsafe Transfer and Lack of Supervision During Resident Handling
Penalty
Summary
Facility staff failed to perform a safe transfer for a resident with multiple complex diagnoses, including traumatic brain injury, cognitive communication deficit, muscle weakness, chronic kidney disease, aphasia, depression, schizophrenia, and PTSD. Video evidence showed that a CNA and a CMT transferred the resident from a Geri-chair to a bed without using a gait belt, despite the resident being visibly upset, screaming, and thrashing. The CNA lifted the resident by the back of the pants while the CMT held the resident's arms, and they released the resident quickly onto the bed. The transfer was not performed according to safe transfer techniques, and the resident's care plan did not include specific instructions for transfers. Interviews with facility staff revealed that CNAs are trained to walk away and return later if a resident is upset and unable to be redirected, and that a gait belt should always be used for transfers. However, the CNA involved stated she never uses a gait belt for this resident and proceeded with the transfer because the resident had been in the chair for more than two hours. The care plan lacked guidance on transfer requirements, and staff did not follow established procedures for safe resident handling, resulting in a failure to provide adequate supervision and prevent accident hazards.