Resident Fall Due to Inadequate Supervision During Transfer Preparation
Penalty
Summary
A deficiency occurred when a resident with significant physical impairments, including aphasia, hemiplegia, and contractures, was left unattended on the edge of a bed in a high position. The resident was dependent on staff for all activities of daily living and required a mechanical lift with two-person assistance for transfers. On the day of the incident, a CNA prepared the resident for transfer by placing the Hoyer lift sling under him but then left the room to retrieve the lift and another staff member, leaving the resident on the edge of the bed, which remained in a high position. During the CNA's absence, the resident fell from the bed and was found on the floor with an abrasion to the left lateral knee. Interviews with facility staff confirmed that the CNA did not follow proper procedures, as the resident should not have been left unattended, especially in a high bed position and near the edge. The resident's care plan specified that the bed should be in a low position and that all equipment should be ready prior to care. Staff acknowledged that the actions taken did not align with the resident's safety needs, particularly given his inability to control spastic movements.