Failure to Provide Timely Transfer Assistance and Access to Call System
Penalty
Summary
The deficiency involves the facility’s failure to provide timely transfer assistance to a resident who required staff support for activities of daily living. The resident was admitted with sepsis, lobar pneumonia, and acute respiratory failure with hypoxia, and the admission MDS documented a BIMS score of 14, indicating the resident was cognitively intact but dependent for wheelchair mobility. A nursing care note documented that after dinner the resident was assisted back to their room and left alone in a wheelchair while staff went to obtain a second person for a two-person transfer. Staff did not return to the room for over an hour. A risk management report completed by an LPN confirmed the resident remained alone in the wheelchair in the room for over an hour awaiting transfer assistance. The resident later stated they were left alone for approximately one hour and ten minutes, did not have a call light or phone within reach, experienced pain, and were unable to transfer or move the wheelchair independently. A CNA reported being assigned both to the resident and to dining room duties and stated she could not leave the dining room while residents were still eating, so she requested another CNA to assist the resident back to the room; she later found the resident still sitting alone in the wheelchair awaiting transfer to bed. Multiple facility leaders, including the assistant administrator in training, field lead, chief nursing officer, and assistant chief nursing officer, acknowledged the resident should have received more timely transfer assistance.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.