Failure to Provide Adequate Supervision and Safe Transfer Practices Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that residents remained free from accident hazards and did not provide adequate supervision and assistance during transfers, resulting in a significant incident involving a resident. On the date in question, a certified nursing assistant (CNA) used a mechanical/Hoyer lift to transfer a resident without the required assistance of a second staff member, contrary to facility policy and the resident's care plan. The CNA proceeded with the transfer alone because other staff were busy, and during the process, the resident fell from the lift, sustaining a fractured right humerus and a closed head injury. The incident was immediately reported, and the resident was assessed and sent to the hospital for further evaluation. The resident involved was an elderly female with multiple diagnoses, including schizoaffective disorder, dementia, generalized anxiety, a history of breast cancer, cognitive communication deficit, and major depressive disorder. She had significant cognitive impairment, as indicated by a low BIMS score, and required extensive assistance for mobility and transfers, including the use of a Hoyer lift with two staff members as specified in her care plan. At the time of the incident, the resident was unable to recall how her arm was broken and demonstrated physical limitations, such as difficulty gripping items and an inability to reach for dropped objects, necessitating reliance on staff for assistance. Interviews and record reviews revealed that the facility's policy required two staff members for all mechanical lift transfers, and this was known to the staff, including the CNA involved. However, prior to the incident, the facility did not perform competency checks for agency staff, relying instead on the agency's assurance of staff competency. The CNA admitted to being aware of the two-person requirement but chose to proceed alone. The facility's failure to verify agency staff competencies and ensure adherence to established transfer protocols directly contributed to the resident's fall and subsequent injuries.