Failure to Prevent Accidents Due to Improper Transfers and Inadequate Supervision
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that residents received adequate supervision to prevent accidents, as evidenced by two separate incidents involving two residents. In the first incident, a resident with a history of cerebrovascular accident, severe cognitive impairment, and total dependence for transfers was transferred using a Hoyer lift by a certified nurse aide and a private aide who was not authorized or trained to provide clinical care. During the transfer, a safety strap on the lift became loose, causing the resident to strike the back of their head on a piece of furniture, resulting in a hematoma. The certified nurse aide involved had received training on the proper use of mechanical lifts and was aware of the requirement for two trained staff to perform such transfers, but allowed an untrained private aide to assist, contrary to facility policy and the resident's care plan. In the second incident, another resident with cellulitis and bilateral knee osteoarthritis, who was care planned and ordered to be transferred via Sara lift with two staff assistance, was transferred by a single certified nurse aide without the use of the mechanical lift. The aide did not use the Sara lift because a required lift pad was missing and decided to transfer the resident manually, despite knowing the resident required two-person assistance and mechanical support. As a result, the resident's knee struck the metal part of the bed, leading to swelling, redness, warmth, and complaints of pain. The aide acknowledged violating the care plan and physician order, and the resident continued to experience pain following the incident. Both incidents were confirmed through record review and staff interviews, which revealed that staff were aware of the facility's policies and the residents' care requirements but failed to follow them. The involvement of unauthorized personnel in direct care and the failure to use required mechanical devices and adequate staff assistance directly contributed to the residents sustaining injuries. These deficiencies resulted in actual harm to both residents, though the situation was not classified as Immediate Jeopardy.