Failure to Provide Adequate Supervision and Safe Transfer Leading to Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide adequate care and supervision to prevent an accident involving a resident with severe cognitive impairment and a history of falls. The resident, who was totally dependent on staff for mobility and required a two-person assist with a Hoyer lift for transfers, was transferred and repositioned in bed by a single CNA, contrary to facility policy and the resident's care plan. The CNA positioned the resident on the edge of the bed, with the resident's head and leg hanging over the side, and then turned away from the resident, leaving them unsupervised and unsupported. As a result of this improper positioning and lack of supervision, the resident rolled off the bed headfirst onto the floor, sustaining multiple bruises and abrasions to the left arm, face, and hip. Video footage provided by a family member confirmed that the CNA was alone during the transfer and that the resident was not combative or resistive at the time of the fall. The CNA admitted to transferring the resident alone with the Hoyer lift and acknowledged that this was against facility policy, citing difficulty in obtaining assistance from other staff. Interviews with other staff members and review of facility policies confirmed that the use of the Hoyer lift required two staff members at all times and that residents should be positioned in the center of the bed during care to prevent falls. Despite these policies, it was revealed that single-person Hoyer transfers had occurred previously due to staffing issues. After the fall, the resident was lifted from the floor by staff without the use of a lift or assistive device, which was also against policy. The incident was initially reported as a non-injury fall, but subsequent assessment and family-provided photos documented significant bruising and swelling.