Untrained Staff Performed Improper Transfer Resulting in Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect by allowing an untrained Hospitality Aide to perform a transfer using the resident's personal sit-to-stand transfer device. The aide was not trained or oriented to use this equipment, and no staff in the facility had received training or competency checks for its use. Despite the Director of Therapy informing the former DON that staff should not use the device and that there was no manual for it, the device remained in the resident's room and was used by staff without proper authorization or training. The resident involved had significant medical needs, including paraplegia, muscle weakness, unsteadiness, osteomyelitis, and thoracic spine pain. Her care plan required assistance with transfers and specified the use of a sit-to-stand device, which was later discontinued after the incident. On the day of the event, the Hospitality Aide, who was not permitted by her job description to perform transfers, responded to the resident's call light after it had been on for about 20 minutes. The aide admitted to not knowing how to use the device but proceeded with the transfer at the resident's request, resulting in the resident falling and sustaining a left knee fracture. Interviews and record reviews confirmed that the Hospitality Aide was not trained for transfer skills until after the incident, and other staff members also lacked training on the device. The administrator was unaware that untrained staff were performing transfers and believed that the prior DON had ensured all necessary training. The Director of Therapy had communicated concerns about the device's use, but these were not acted upon. The incident was captured on video, and subsequent interviews with staff and the resident confirmed the lack of training and improper transfer procedures that led to the resident's injury.