Failure to Provide Timely Transfer Due to Unavailable Lift Slings
Penalty
Summary
The facility failed to provide necessary care to ensure a resident's activities of daily living (ADLs) needs were met, specifically regarding timely transfers out of bed. According to facility policy, care should be provided in a safe, appropriate, and timely manner in accordance with the resident's care plan. The resident in question had a history of dementia, chronic pain, anemia, and mobility issues, and was dependent on staff for transfers, requiring a full body lift with two staff members. On the day of the incident, the resident was placed back in bed around 1:00 PM after their sling became soiled and was put in the wash. Staff informed the resident's responsible party that the slings were unavailable as they were being washed, and the resident remained in bed for the rest of the evening, despite requests to be transferred out of bed. Interviews with staff confirmed that the resident was not transferred out of bed due to the lack of clean slings for the mechanical lift, and this was communicated during shift changes. The Director of Nursing and the Administrator both stated that residents dependent on staff for transfers should be assisted out of bed as per their care plan and requests. The Director of Nursing also noted that all slings should not have been washed at the same time, which contributed to the unavailability of necessary equipment and the failure to meet the resident's care needs.