Failure to Provide Adequate Supervision and Safe Transfer Assistance
Penalty
Summary
Staff failed to provide adequate supervision and assistance to prevent accidents for a resident with severe cognitive impairment, limited mobility, and a history of repeated falls. The resident required a Hoyer lift with two staff for all transfers, as documented in the care plan and facility policy. However, one CNA, unaware of the resident's transfer requirements, used a gait belt instead of the Hoyer lift to transfer the resident from bed to wheelchair. This method was not in accordance with the resident's care plan or facility policy, which mandates mechanical lifts and two-person assistance for residents needing such support. Later, another CNA observed the resident sliding out of a wheelchair and, unable to locate a second staff member, used the Hoyer lift alone to transfer the resident back to bed. This action was also contrary to facility policy and training, which require two staff members for Hoyer lift transfers to ensure resident safety. Multiple staff interviews confirmed that all were trained to use two people for Hoyer lift transfers and to wait for assistance if a second person was not immediately available. Following these improper transfers, the resident was found with a hematoma on the back of the head and a swollen leg. The resident was sent to the hospital, where imaging revealed a closed fracture of the proximal left tibia. Documentation and interviews indicated that the improper transfer methods directly preceded the discovery of these injuries, and staff statements confirmed deviations from established transfer protocols.