Improper Manual Transfer and Handling Causing Psychosocial Harm
Penalty
Summary
The deficiency involves staff failing to provide care and transfers in accordance with the resident’s care plan, professional standards, and facility policy for a resident with severe cognitive impairment who frequently moved from the bed to a floor mattress. The resident’s room contained a hospital bed in the lowest position with a hospital mattress placed on the floor alongside the bed, and the resident was known to occasionally lie on the floor mat. The resident’s admission history and physical documented cognitive impairment, limited capacity to understand instructions, significant hearing impairment, and dependence on others for mobility, with hospice care in place. The MDS and care plan identified the resident as a fall risk, dependent for all cares and transfers, and required assistance of two staff with a mechanical (Hoyer) lift and a medium sling for transfers, with a fall mat and low bed as interventions. Video review from the resident’s room showed that on the morning in question, the resident was partially on the bed and partially on the floor, lying on her back with her hips and legs on the floor and upper body on the bed, dressed in a gown without undergarments. One nursing assistant stood at the center of the bed, bent over, grasped the front of the resident’s gown near each armpit with both hands, and dragged the resident from the floor mattress onto the bed. The assistant paused with the resident partially on the bed, then, together with a second nursing assistant, manually manipulated the resident’s legs and hips to reposition her fully onto the bed. The resident was turned into a prone position with her head at the head of the bed, feet at the bottom, face down, initially with one arm tucked under her chest; when the assistant pulled that arm out, the resident moaned. The resident was left in a prone position on the bed, exposed from the waist down without undergarments. Interviews confirmed that staff were aware the resident’s care plan and NA guide required two-person assistance with a mechanical lift for transfers and that the facility’s Safe Resident Handling policy directed that residents unable to bear weight be transferred with lift equipment instead of manual lifting. One nursing assistant stated the resident frequently crawled off the bed to the floor mattress and acknowledged knowing a mechanical lift and two staff were required, but reported that she and another assistant had been transferring the resident back to bed in a similar manual manner over previous weeks because they felt there was not enough room in the room to use the lift around the large floor mattress. Neither assistant reported these challenges or their deviation from the care plan to nursing staff, the clinical leader, or the DON. Family reported hearing the resident say “hurt, hurt” in her language while viewing the video and described the transfer as abusive and not consistent with the resident’s cultural preferences, and the surveyors applied the reasonable person concept to determine psychosocial harm from the noncompliant transfer and handling.
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