Failure to Provide Required Transfer Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide required ADL assistance with transfers for a resident who was fully dependent on staff for all transfers, toileting hygiene, and bathing. The resident had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and COPD, and required the use of a mechanical lift for all transfers from bed to wheelchair. The resident’s MDS documented that she was cognitively intact with a BIMS score of 15 and dependent on staff for all transfers. Despite this documented need, the resident reported that when the facility was short staffed, she was unable to get out of bed because there were not enough staff available to perform the lift transfer. During an interview, the resident stated that on a specific date she could not get out of bed due to staffing shortages and recalled this date because she documented it on her phone. She reported that the DON told her that, due to short staffing, she would either need to remain in bed or stay in her wheelchair until late in the evening, around 9:00 pm or 10:00 pm, when staff would again be available to transfer her. The resident stated it was painful to remain in her wheelchair that long, so she stayed in bed. In a subsequent interview, the DON stated she did not remember having that conversation with the resident but confirmed that it takes extra staff to transfer this resident because she requires a mechanical lift for all transfers.
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