Failure to Protect Resident During Mechanical Lift Transfer and to Supervise At-Risk Smoker
Penalty
Summary
Surveyors identified that staff failed to protect a resident’s heels during a mechanical lift transfer. One resident with moderately impaired cognition, bilateral leg nerve damage causing muscle weakness, a history of stroke, and a documented moderate risk for pressure ulcer development required extensive assistance with ADLs and mobility. His care plan directed staff to follow facility protocols for prevention of skin breakdown. During observation of a bed-to-wheelchair transfer using a mechanical lift, an OT and a CNA repositioned the resident in the sling while his heels dragged across the mattress. After transfer, the OT exposed the resident’s heels and noted redness on the right heel. Multiple CNAs later stated that residents’ feet and bodies should not contact the mattress while being actively moved with a mechanical lift, and the DON stated staff should have lowered the bed or elevated the heels to prevent shearing or rubbing. The facility’s Safe Resident Handling/Transfers policy required safe handling and transfers to prevent or minimize injury and provide a safe, comfortable experience. Surveyors also found that staff failed to provide required supervision for an at-risk smoker who accessed the courtyard alone. Another resident with intact cognition but significant physical impairments, including hemiplegia, stroke, acute respiratory failure, hypertension, and diabetes, required extensive assistance with mobility and ADLs. A progress note and a Safe Smoking Assessment documented that he was not an independent smoker, lacked spatial and self-awareness, and required supervision for smoking. His care plan directed staff to supervise smoking, ensure cigarettes were fully extinguished, and assist him to and from the designated smoking area as needed. On one early morning, the resident wheeled himself through an exit door into the enclosed smoking courtyard by canceling the door alarm and activating the automatic door opener, with no staff present and no audible alarm heard. On another early morning, he opened the courtyard door and triggered the alarm, to which the DON immediately responded and reminded him he needed staff present to smoke. The facility’s Resident Smoking policy required that supervision be provided as indicated on each resident’s care plan.
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