Failure to Provide Adequate Supervision and Assistance During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance to prevent accidents, resulting in actual harm. A resident with a history of stroke and hypertension had a care plan and physical therapy discharge summary indicating the need for transfer with a stand aid and assistance from two staff members. Despite this, a nurse aide transferred the resident from a wheelchair to bed alone, using a stand pivot technique, rather than the required stand aid with two-person assist. This action was not in accordance with the resident's care plan or the facility's 'No Lift Program' policy, which prohibits transfers without the required equipment and staff. As a result of the improper transfer, the resident sustained a significant laceration to the right lower leg, measuring 10 cm x 8 cm x 1 cm, with exposure of the fatty layer, and required 15 sutures at the hospital. The nurse aide involved stated she was unaware of the need for two-person assist with a stand aid for transfers, having only seen the one-assist requirement for toileting in the care guide and not scrolling further to see the transfer instructions. The facility's investigation confirmed that the staff member did not follow the resident's care plan, leading to the injury.