Failure to Update Assignment Sheet Leads to Resident Injury During Transfer
Penalty
Summary
The facility failed to prevent accidents by not ensuring that the assignment sheet accurately reflected the care needs of a resident with Alzheimer's disease, osteoarthritis, and a history of repeated falls. The resident was involved in an incident where, while being transferred using a stand-up lift, she moved her left arm and did not hold onto the bar, resulting in a skin tear to her left forearm. Occupational therapy notes indicated that the resident had limited standing tolerance and required significant assistance and constant cues to keep her feet on the lift platform. It was also documented that transfers using the sit-to-stand lift should only be performed by CNAs familiar with her behavior and who had been educated on her specific needs. Despite these documented requirements, staff involved in the transfer were not fully aware of the resident's current transfer status, with one employee stating they believed the resident was cleared for the sit-to-stand lift based on previous information. The assignment sheet, which is used by CNAs to determine transfer statuses, was not updated to reflect the resident's need for a two-person transfer and the specific precautions required. Although competency evaluations and orientation for mechanical lift use were in place, the lack of accurate and updated information on the assignment sheet contributed to the incident.