Failure to Provide Adequate Supervision During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with hemiplegia, diabetes, and a history of falls, who was dependent on staff for bed-to-chair transfers and required the assistance of two staff members for transfers, was not provided adequate supervision during a transfer. The resident's care plan and facility policy specified that two staff members were required for all transfers and for moving the resident from lying to sitting on the side of the bed. Despite this, a CNA attempted to transfer the resident alone, resulting in the resident sliding out of bed and sustaining a left humerus fracture. The CNA involved had received training and demonstrated competencies in safe transfer methods and was aware of the resident's care requirements. The incident report and the CNA's written statement confirmed that the CNA sat the resident at the edge of the bed while waiting for help, but the resident slid forward and fell, injuring her shoulder. The facility's policies emphasized minimizing safety hazards and ensuring safe handling and transfers, but these were not followed in this instance. Interviews with multiple CNAs, LPNs, and RNs confirmed that staff were trained to use the Kardex and care plans to guide safe care and that education on safe transfers was provided. However, the failure to follow the resident's care plan and facility policy directly led to the resident's fall and injury. The deficiency was identified as past noncompliance, and facility leadership acknowledged the failure to provide adequate supervision to prevent the accident.