Failure to Provide Required Two-Person Assistance During Resident Transfer Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident, a 93-year-old woman with a history of left femur fracture, peripheral vascular disease, and congestive heart failure, was not provided with the required level of assistance during a transfer from the toilet to her wheelchair. The resident's care plan and clinical assessments specified that she required a two-person assist and the use of a mechanical lift for transfers. On the date of the incident, only one CNA assisted the resident off the toilet, despite the care plan requirements. The resident's knee gave out during the transfer, causing her to fall and hit her knee on the toilet paper dispenser. She complained of pain, and subsequent x-rays revealed a broken femur, necessitating hospitalization and surgery. Interviews and record reviews revealed that the facility had ongoing staffing shortages, which led to frequent instances where only one staff member performed transfers that required two people. Multiple staff members, including CNAs and the ADON, acknowledged that one-person transfers for residents requiring two-person assistance were common due to inadequate staffing. Video evidence provided by the resident's representative also showed several instances where the resident was transferred by one staff member, both with and without a mechanical lift, in violation of facility policy and the resident's care plan. Further investigation indicated that some staff were unaware of how to access the resident's transfer requirements in the electronic Kardex, and communication lapses contributed to the failure to provide adequate assistance. The facility's own policies required two staff members for mechanical lift transfers and for residents assessed as needing two-person assistance. Despite these requirements, staff routinely performed one-person transfers, and the incident in question was directly linked to these practices. The deficiency was identified as Immediate Jeopardy due to the risk and actual harm caused to the resident.
Removal Plan
- Assess all residents requiring 2 person assist during transfer for any injuries.
- Provide 1:1 in-service to the CNA involved on Abuse and Neglect Policy, Mechanical Lifts Transfer, and use of the Electronic Medical Record for ADL Care Plan.
- Provide CNA retention checks, including written in-service cheat sheets for quick reference, obtain signature and verbal acknowledgements, and require return demonstration from CNA with all transfers with rehab director.
- Provide 1:1 in-service to the administrator, DON, and ADONs by the Regional Compliance Nurse and ADO on Abuse and Neglect Policy, Mechanical Lift Transfers, and use of the Electronic Medical Record for ADL Care Plan, and determine competency by post test.
- Assess and determine staffing levels daily in accordance with the census and facility assessment, offer extra shift bonuses to staff as needed, provide sign on bonuses to attract new employees, contact company sister facilities for staffing assistance as needed, and build out the schedule at least 1 week in advance.
- Provide employee retention checks to Administrator and DON, including written in-service cheat sheets for quick reference, obtain signature and verbal acknowledgements.
- In-service all certified and licensed staff on Abuse and Neglect Policy, Mechanical Lift Transfers, and use of the Electronic Medical Record for ADL Care Plan, require all staff not present for the in-services to complete them before working, in-service all new hires during orientation, require staff to sign the in-service sheet, in-service all agency staff before scheduled shift, provide a posttest to confirm understanding, and require return demonstration for mechanical transfer check-off.
- Notify the Medical Director of the immediate jeopardy citation.
- Conduct ADHOC QAPI meeting with the IDT Team and the Medical Director to review the immediate jeopardy citation and plan of removal.