Failure to Provide Adequate Supervision and Assistance During Resident Transfers
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, as required by facility policy and resident care plans. For one resident with a history of hypertension, stroke, and hemiplegia, the care plan specified bed mobility assistance from two staff members and that the bed should remain in a low position. However, a nurse aide raised the bed, left it in a high position, and left the resident unattended while retrieving linens, resulting in the resident falling from the bed and sustaining a minor skin tear. The nurse aide did not follow the prescribed two-person assist protocol or maintain the bed in the required low position. Another resident, dependent for transfers due to diagnoses including hypertension, renal insufficiency, and heart failure, had physician orders and a care plan requiring transfer with a walker and assistance from two staff members, with a Hoyer lift as needed. Despite this, a nurse aide attempted to transfer the resident with only one staff member, leading to the resident losing balance and being lowered to the floor. No injuries were noted in this incident. In both cases, the Director of Nursing confirmed that staff failed to provide the required level of supervision and assistance as outlined in the residents' care plans.