Inadequate Supervision and Improper Transfer Technique Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) attempted to transfer a resident who required a two-person assist with a Hoyer lift, using a sliding board and without assistance from another staff member. The resident, who had a history of Parkinson's disease, prior stroke with left-sided deficits, non-Alzheimer's dementia, hemiplegia, and was on blood thinners for atrial fibrillation, was care planned for two-person Hoyer lift transfers due to her high risk for injury and fear of falling. Despite these documented needs, the CNA proceeded with a one-person sliding board transfer, for which she was not trained or delegated, and did not request help from another staff member. During the transfer, the CNA left the resident unattended while preparing the bed, at which point the resident attempted to scoot forward onto the sliding board from her wheelchair. The resident lost balance, fell to the floor, and struck her head. The incident was witnessed by another CNA who heard the fall and immediately notified the charge nurse. Upon assessment, the resident was found to have a hematoma on the left side of her head, bruising to both hands, and was subsequently sent to the hospital where a CT scan revealed a subarachnoid hemorrhage in the left temporal lobe. Interviews with staff and review of facility policies confirmed that nursing staff were not permitted to use sliding boards for this resident, and that at least two staff were required for mechanical lift transfers. The CNA involved admitted to not being trained for sliding board transfers for this resident and acknowledged that the resident was normally a two-person assist. The therapy department had been working with the resident on sliding board transfers, but only therapy staff were authorized and trained to perform them. The facility did not provide a specific transfer policy when requested.