Failure to Provide Adequate Supervision and Assistance During Resident Transfers
Penalty
Summary
Multiple residents who required two-person assist or mechanical lift transfers were transferred by a single nurse aide, contrary to physician orders and facility policy. In each case, the assigned aide was aware of the resident's transfer status, as indicated by daily planners, color-coded stickers, and shift reports, but proceeded to transfer the resident alone due to the unavailability of additional staff or in an attempt to expedite care. These actions resulted in actual harm to the residents, including a head contusion and skin tears. One resident with diagnoses including high blood pressure, glaucoma, and anemia sustained a contusion to the left side of her head after a CNA, acting alone, attempted to transfer her from the toilet without using the required Sara lift and second staff member. The CNA admitted to transferring the resident independently to hurry the process, which led to both the resident and the aide bumping heads. The resident developed a raised, bruised area on her head as a result. Two other residents, both with significant medical histories such as high blood pressure, diabetes, heart failure, and osteoporosis, suffered skin tears during transfers. In both cases, the CNAs assigned to them acknowledged that they were aware of the two-person assist requirement but proceeded to transfer the residents alone because they could not find available help and the residents urgently needed assistance. These transfers resulted in actively bleeding skin tears that required immediate first aid. Interviews with other staff confirmed that transfer statuses are clearly communicated and that staff are educated not to transfer residents alone when two-person assistance is required.