Failure to Provide Adequate Supervision and Assistance During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow established protocols during a bed-to-wheelchair transfer for a resident. The resident, who was dependent on staff for transfers and required assistance from two staff members as per her care plan, was transferred by only one CNA without the use of a gait belt. The CNA was unable to stabilize the resident during the transfer, resulting in the resident falling forward onto the floor. The resident involved had multiple medical conditions, including kidney failure, gastrointestinal hemorrhage, osteoarthritis, and chronic obstructive pulmonary disease. She was cognitively intact and required total assistance for transfers, as documented in her care plan and Minimum Data Set (MDS) assessment. During the incident, the resident sustained a laceration to her nose and left upper extremity, and complained of pain in her neck and extremities. Emergency medical services were called, and the resident was found to have fractures in her neck (C1-C2), necessitating transfer to another hospital for surgery. Interviews and record reviews confirmed that the facility's procedural guidelines required the use of a gait belt and assistance from additional staff for such transfers. Staff members, including the CNA involved, acknowledged that they had been trained on these procedures. However, the CNA did not adhere to the care plan or facility policy at the time of the incident, directly leading to the resident's fall and subsequent injury.