Failure to Provide Safe Transfers and Adequate Supervision
Penalty
Summary
A deficiency occurred when staff failed to provide a safe transfer for a resident with severe cognitive impairment, hemiparesis, and total dependence on staff for transfers. The resident's care plan required two staff members and the use of a gait belt for all transfers. However, a contract health care technician (HCT) performed a stand/pivot transfer alone, without assistance, and allowed the resident to fall hard into a recliner instead of assisting him down. This action was witnessed by another staff member and confirmed by video review. The staff member involved admitted to transferring the resident alone, acknowledging it was against protocol. Another deficiency was identified when a resident with profound intellectual disabilities, seizure disorder, and a high risk for falls was left unattended on the toilet by a health care technician. The resident's care plan specified that staff must remain close by during toileting to prevent falls or injury. Instead, the staff member left the resident alone in the bathroom for an extended period, during which the resident fell and was found on the floor by another staff member. The staff member responsible was found to have been away from the resident for approximately 44 minutes, during which time she was observed in the breakroom. Both incidents were corroborated by staff interviews, written statements, video surveillance, and internal investigation reports. In both cases, the residents were assessed after the incidents, with one sustaining a small bruise and the other showing no signs of injury or distress. The failures to follow established care plans and supervision protocols directly led to the deficiencies cited in the report.