Failure to Provide Adequate Supervision During Resident Transfer Resulting in Harm
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and required a two-person assist as documented in the care plan and Kardex, was transferred by a single CNA. The resident had significant medical conditions, including COPD, heart failure, diabetes, and was non-weight bearing on the left lower extremity. The care plan specifically indicated the need for caution during transfers to prevent skin injuries, and the Kardex clearly stated the requirement for a two-person assist for transfers. During the transfer from wheelchair to bed, the CNA performed the task alone, contrary to the documented requirements. The resident's right shin struck the wheelchair leg rest holder during the transfer, resulting in a deep skin tear. The injury was discovered after the transfer when the resident's pants were removed, revealing a large, deep skin tear with exposure of adipose tissue. The wound measured 4.5 cm by 5 cm, was 1 cm wide and deep, and required immediate medical attention. The incident was reported by the CNA and assessed by nursing staff, who confirmed the extent of the injury. The resident was sent to the hospital, where the wound required 17 sutures. Documentation and staff interviews confirmed that the CNA did not check the resident's transfer status prior to the transfer and did not follow the required two-person assist protocol, directly leading to the resident's injury.