Failure to Provide Required Supervision and Assistance During Resident Transfers
Penalty
Summary
A deficiency occurred when a resident with significant physical and cognitive impairments did not receive adequate supervision and assistance during transfers. The resident, diagnosed with Alzheimer's disease, hemiplegia, generalized muscle weakness, unsteadiness, and other mobility issues, was care planned and assessed as requiring extensive assistance for bed mobility with one person and total dependence with two-person physical assist for transfers. However, interviews and record reviews revealed that staff routinely transferred the resident alone, using a 'bear hug' technique, despite documentation indicating a two-person assist was required for transfers. Multiple staff members, including CNAs, reported transferring the resident by themselves, stating that the resident was now a one-person assist. Family observations corroborated that the resident was transferred by a single staff member, contrary to the care plan and MDS documentation. There was also inconsistency among staff and administration regarding the use of a gait belt, with conflicting statements about whether it was necessary or appropriate for the resident. The facility's policy required ongoing assessment and documentation of residents' transfer needs, including input from nursing and rehabilitation staff. Despite this, the care plan and MDS were not updated consistently to reflect the resident's actual transfer status, and staff did not follow the documented requirements for assistance. This failure to provide the required level of supervision and assistance during transfers constituted a deficiency in ensuring the area was free from accident hazards and that adequate supervision was provided to prevent accidents.