Failure to Ensure Adequate Supervision and Assistance During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident was free from neglect by not providing adequate supervision and assistance during a transfer. According to the clinical record, a resident with diagnoses including high blood pressure, hyperlipidemia, and arthritis required transfers using a full body mechanical lift with the assistance of two staff members, as indicated by physician orders and the resident's care plan. On the day of the incident, a Certified Nurse Aide (CNA) attempted to transfer the resident alone using the Hoyer lift. During the transfer, the lift tilted, and the CNA had to lower the resident to the floor. The resident reported hitting her head and left shoulder and subsequently requested to go to the emergency room for head pain. Staff interviews and documentation revealed that the CNA was pressured by the resident's spouse to expedite the transfer so they could go outside. The Nursing Home Administrator and Director of Nursing confirmed that the facility did not ensure the required supervision and assistance for the transfer, resulting in neglect as defined by facility policy. The incident was substantiated through review of facility policy, clinical records, and staff interviews.