Failure to Provide Timely ADL Assistance with Transfers for Dependent Resident
Penalty
Summary
A dependent resident with multiple diagnoses, including multiple sclerosis, anxiety disorder, chronic pain syndrome, abnormal posture, repeated falls, muscle weakness, ataxic gait, and fatigue, was not provided timely assistance with activities of daily living (ADLs), specifically with transfers. The resident was documented as fully dependent for transfers and required the use of a mechanical lift with the assistance of two staff members. On the morning in question, the resident's breakfast was left untouched in the dining room because she had not been transferred out of bed. Staff interviews revealed that there was only one CNA available on the floor during the early morning hours, making it impossible to perform the required two-person mechanical lift transfer. As a result, the resident remained in bed and was unable to join the dining room for breakfast, despite expressing her preference to do so and being alert and oriented during the interview. Further interviews with staff indicated that the night shift did not get any two-assist residents up in the morning, and the available CNA prioritized getting up residents who required only one-person assistance. The Director of Nursing and the Administrator both stated that there should always be enough staff in the building to assist with mechanical lift transfers, and that no resident should be left in bed due to staffing issues. Facility policy requires two qualified staff for mechanical lift transfers. The failure to provide timely ADL assistance with transfers for this dependent resident was directly observed and confirmed through staff interviews and record review.