Failure to Ensure GNA Competency in Resident Transfers and Toileting
Penalty
Summary
The deficiency involves the facility’s failure to ensure that GNAs possessed and demonstrated appropriate competencies for safe resident care, as evidenced by two resident incidents and missing competency documentation. In the first case, a resident who, according to the care plan, required moderate assistance of one staff member for toileting was left alone on the toilet by the assigned GNA. The resident attempted to transfer independently from the toilet and fell in the bathroom, which was the second fall within a week while attempting to use the toilet. The facility’s fall investigation, reviewed with the DON, confirmed that the GNA did not follow the resident’s care plan by failing to remain with and appropriately transfer the resident. Review of this GNA’s employee file showed no annual evaluations of skill sets or online training, and the acting Corporate Clinical Resource Nurse/NPE/IP/QA nurse stated she was not aware of where employee certificates were kept and did not provide additional documentation. In the second case, a facility-reported incident involved a resident with a broken left leg who complained of pain after being transferred by the assigned GNA. The resident reported pain to the nurse and stated they had been inappropriately transferred, and an investigation was not initiated until the resident’s daughter later called to report ongoing pain and the allegedly improper transfer to a bedside commode. During the facility’s investigation, the GNA reported that during the first transfer back to bed, she provided contact guard support by holding the resident’s ankles, and during a second transfer, she lifted the resident’s legs off the bed, at which point the resident began yelling that they were being hurt. Review of this GNA’s personnel file showed that, although she had been hired months earlier, there was no new-hire skills checklist or annual evaluation of GNA skills. The DON acknowledged concerns about the lack of training and education, and these concerns were presented to facility leadership during the survey.
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