Failure to Ensure Adequate Supervision and Assistance During Resident Transfers Resulting in Harm
Penalty
Summary
The facility failed to ensure residents were free from neglect by not providing adequate supervision and assistance during transfers, resulting in actual harm to multiple residents. In several documented incidents, residents who required two-person assistance or mechanical lifts for transfers were instead transferred by a single nursing aide, contrary to physician orders and facility policy. This led to injuries including a head contusion for one resident and skin tears for two others. In each case, the aides involved acknowledged they were aware of the required transfer status but proceeded alone due to the unavailability of additional staff or in an attempt to expedite care. One resident with diagnoses including high blood pressure, glaucoma, and anemia sustained a head contusion after a CNA transferred her independently instead of using the required mechanical lift with two staff. Another resident with high blood pressure, hyperlipidemia, and diabetes suffered a skin tear to her lower extremity during a solo transfer by a CNA, despite being ordered for a two-person mechanical lift assist. A third resident, with high blood pressure, heart failure, osteoporosis, and moderate cognitive impairment, also sustained a significant skin tear when transferred by a single aide, who admitted knowing the resident's two-person assist status but was unable to find help at the time. Additionally, the facility failed to document, assess, and investigate an unexplained skin injury for one resident, as required by policy. There was no record of physician notification, assessment, or follow-up for a skin condition that required a dressing, and staff interviews confirmed that the appropriate procedures were not followed. The DON and other staff confirmed these failures to ensure adequate supervision, adherence to transfer protocols, and proper incident documentation, resulting in neglect and actual harm to the residents involved.