Failure to Provide Adequate Supervision During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a male resident, who had a recent joint replacement and multiple comorbidities including dementia, diabetes, and a history of fractures, without the required two-person assistance. The resident's care plan specifically indicated the need for a two-person assist for transfers due to his medical condition and risk factors. Despite this, the CNA performed a stand and pivot transfer alone, did not use a gait belt, and left a cushion between the resident's legs during the process. The transfer was captured on video, and the CNA acknowledged transferring the resident alone on multiple occasions, justifying the action by the resident's small stature. Following the transfer, the resident experienced a dislocation of his right hip arthroplasty, as confirmed by radiographic imaging. The care plan and medical records had not been updated to reflect any changes in transfer needs after the resident's return from hospitalization, and staff interviews confirmed that the resident consistently required two-person assistance for transfers. Multiple staff members, including CNAs, nurses, and the Director of Nursing (DON), stated that improper transfers could result in injury or death, and that the resident was at risk for falls as indicated in his care plan. The facility's policies required the use of proper transfer techniques, including the use of gait belts and adherence to care plans specifying the number of staff needed for transfers. The policy also outlined the responsibilities of staff to communicate changes in mobility needs and to use mechanical lift equipment as appropriate. Despite these policies, the CNA did not follow the established procedures, resulting in an incident that led to the identification of Immediate Jeopardy by surveyors.