Failure to Provide Required Assistance During Transfers and Bed Mobility
Penalty
Summary
Staff failed to provide a resident with the appropriate level of assistance during transfers and bed mobility, contrary to physician orders, care plan interventions, and facility policy. The resident, who had multiple diagnoses including heart failure, muscle weakness, gait abnormalities, and was at high risk for falls, was dependent on staff for all mobility and transfers. The care plan and therapy recommendations specified the use of a mechanical sling lift with two staff members present for transfers and bed mobility to ensure safety and prevent injury. Despite these requirements, there were multiple documented incidents where only one staff member assisted the resident during transfers and bed mobility. In one instance, a single aide used a hygiene sling that was too tight and performed a ceiling lift transfer alone, resulting in the resident's arm being extended and causing pain. The resident reported shoulder pain following the transfer, which persisted for several days and required medical evaluation and pain management. Video evidence confirmed that the transfer was performed by one aide, and the resident was visibly in distress during the process. Another incident involved a single aide providing peri-care and turning the resident in bed without assistance, during which the bed dropped and the aide's face and glasses collided with the resident's face. The resident reported feeling as if she had been hit with a bowling ball, though no injury was noted. Interviews with staff, therapy, and nursing leadership confirmed that two staff members were required for all transfers and bed mobility for this resident, and that the facility's policy mandated the appropriate number of staff for ceiling lift use. The failure to follow these protocols resulted in pain and distress for the resident and was observed to have occurred on more than one occasion.