Inadequate Supervision During Transfer Leads to Resident Injury
Summary
The facility failed to provide adequate supervision and assistance to a resident who was at high risk of falls, resulting in a serious injury. The resident, who had a history of hemiplegia and hemiparesis following a stroke, required the assistance of two staff members for transfers. However, on the day of the incident, a CNA attempted to transfer the resident using a Sit/Stand Lift device without the required assistance of another staff member. During the transfer, the resident began to slide out of the lift seat, and the CNA attempted to lower the resident to the floor, resulting in the resident complaining of hip pain. The resident was initially assessed at the hospital emergency department, where no fractures were found. However, the resident continued to experience pain, and an X-ray conducted at the facility several days later revealed a distal right femur fracture. The fracture was attributed to the forceful movement during the fall, which occurred when the resident was being transferred without the necessary assistance. Interviews with the CNA and other staff members revealed inconsistencies in the account of the incident. The CNA admitted to not using a gait belt or having another staff member assist during the transfer, contradicting earlier statements made to the Physician Assistant, Director of Nursing, and Administrator. The facility's policy required two staff members for such transfers, and the failure to adhere to this policy directly contributed to the resident's injury.
Removal Plan
- Resident #1 fell, was immediately assessed by Nursing for any injuries, Resident #1 had reported he/she had pain to right hip, and was transferred to the Hospital Emergency Department (ED) for evaluation.
- Resident #1's Care Plan was reviewed and updated to include the fall, and to ensure transfer status indicated he/she required physical assistance of two staff for all transfers.
- Resident #1 returned to the facility, nursing reviewed the Hospital ED Discharge Summary (Final Report) which indicated Resident #1 was assessed and treated at the ED with no fractures found. However, he/she continued to experience pain and an X-ray completed at the facility a few days later indicated he/she had a right femur fracture.
- Resident #1's Care Plan was updated to include that Resident #1 was in pain, Facility X-ray indicated Resident #1's right femur was fracture status post fall, which was not previously diagnosed, that he/she had been transferred back to the ED and was admitted to the Hospital.
- The Facility's Morning Meeting and the Weekly Risk Meeting Fall Review minutes indicated the Interdisciplinary Team (IDT) reviewed Resident #1's fall, his/her X-ray results, and need for him/her to be transferred back to the Hospital ED for evaluation. The minutes indicated the IDT continues to discuss (and update as needed) Resident #1's Plan of Care including orthopedic appointments, weight bearing status, nutritional status, and overall health status.
- The Facility Nursing Staff completed an Audit to ensure all residents who used any type of mechanical device, that their individual Care Plan and the CNA Care Kardex indicated the appropriate type of device to be used and how many staff were needed for assistance with the transfer.
- The Staff Development Coordinator (SDC) and the DON initiated mandatory education for all Licensed Nurses and CNA's, which included completion of competencies on Sit/Stand Lift device, and staff were required to complete return demonstration of appropriate use of the transfer device. Education also included nursing staff requirement to review and follow residents plan of care, knowledge of how to access and review the CNA Care Kardex, prior to providing care.
- Resident #1's Care Plan was updated to include, right distal femur fracture related to a fall, and that he/she required extensive assistance from two staff members using a Hoyer Lift (mechanical lift used to safely transfer patients).
- All Sit/Stand Lift devices were Inspected by the Maintenance Department, to ensure all parts were functioning properly and transfer device was safe to use.
- Physical Therapy Department Staff also initiated and completed Audits related to the incident to ensure all residents including new admissions, that their transfer status degree and number of staff needed for assistance during the provision of all care need areas identified were up to date on residents Plan of Care and CNA Care Kardex.
- Random Audits were completed by administrative staff, on Resident transfers with the Sit/Stand Lift to ensure that transfer procedures from Sit/Stand Lift Competencies are being followed by staff. Random Audits will be completed by the DON three times weekly for 3 months.
- The DON presented the Audit results at monthly Quality Assurance Performance Improvement (QAPI) meeting, where the QAPI Committee discussed the results. The DON will present the Audit results for three months, then quarterly until the Committee determines 100% staff compliance is met, and the concern area thereafter will be present for yearly review.
- Review of the facility's most recent QAPI meeting minutes indicated leadership's plan is to continue to review the concern areas for potential deficient practice, including falls, to ensure that residents were provided with appropriate level of assistance as determined by assessments and identified in the residents Plan of Care and CNA Care Kardex.
- The Director of Nurses (DON) and/or designee are responsible for overall compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Follow Fall Interventions: A resident with dementia, ESRD on dialysis, impaired mobility, and a history of falls was observed ambulating and self-transferring in her room and bathroom without staff assistance, despite orders and a care plan requiring one-person assist with a walker, call light use, frequent safety checks, and skid strips by the bed. Staff interviews confirmed the resident was transferring independently and that the skid strips were not in place as documented.
A resident assessed as high risk for falls did not receive the physician-ordered fall mat on the right side of the bed. Surveyors observed no mat during multiple checks, and the TAR did not reflect the intervention. The resident said the mat had been removed after a new bed was placed, while an RN and the DON acknowledged the order remained in place even though the mat was no longer being used.
Smoking safety interventions were not consistently implemented for four residents who smoked. Two residents were observed smoking with staff supervision but without the smoking aprons listed in their assessments and care plans, and two other residents were also observed smoking in wheelchairs without aprons despite care plan interventions requiring them. The DON confirmed the apron requirement for two of the residents, while the ADON stated residents sometimes complained about the aprons and that he did not know when smoking assessments were completed.
A resident with cerebral palsy, severe cognitive impairment, wheelchair use, and a care plan requiring a mechanical lift for all transfers was manually transferred by a CNA instead of using the lift. During observation, the CNA lifted the resident by the upper back and moved him between the wheelchair and bed without mechanical assistance, despite having completed lift competency training and despite the DON confirming the resident required a mechanical lift for all transfers.
Failure to supervise a resident at risk for elopement led to repeated exit-seeking and wandering events, including being found off the unit and near exterior areas. The resident had dementia with cognitive impairment, hemiplegia, and diabetes, and staff notes described missing documentation of several wandering episodes, an incomplete care plan intervention, and incidents involving a broken alarmed door, a Wanderguard, and an unknown visitor letting the resident off the unit.
A resident with severe cognitive impairment fell during a lift transfer when a sling strap came loose and the chest strap clip broke, and two other residents were observed being transferred with total body lifts using slings that were not verified against their care plans or mobility assessments. Staff interviews showed some CNAs relied on the sling already in the room or on how it fit, rather than consistently checking the care plan or Kardex for the correct sling size and transfer method.
Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure that a resident's fall interventions were in place for one resident reviewed for falls. The resident had diagnoses of dementia and end-stage renal disease requiring dialysis, was documented as having intact cognition but needing supervision with ADLs, transfers, and walker use, and was identified as a fall risk due to ESRD, impulsive behavior, and impaired mobility. The resident's nursing and provider orders directed staff to assist with ambulation, remind the resident to use the call light and wait for staff, and complete frequent safety checks each shift. The resident had a documented fall in which she was found sitting on the floor between her drawer and walker with bleeding from a forehead injury and a skin tear to her jaw, and she was transferred to the hospital where she received stitches. The incident report stated the resident lost her balance when she walked to her drawer to close it. The resident's care plan later identified a self-care performance deficit related to actual falls, weakness, and impaired mobility, and included interventions such as assistance from one staff member with a walker and gait belt, assistance with transfers and toileting, use of assistive devices, skid strips next to the bed, and frequent monitoring for safety. During observations, the resident was seen ambulating and self-transferring in her room and bathroom without staff assistance and at times without using her walker or call light. Staff observed the resident walking independently in her room, and an unidentified staff member passed by without entering the room. The resident stated that she walked and used the bathroom by herself and did not need to follow instructions. Staff interviews confirmed that the resident transferred independently and ambulated without a walker or staff assistance, while another nurse stated the resident was not supposed to self-transfer and that skid strips were not present despite being listed in the care plan. The DON stated that staff were expected to follow resident orders and care plans for safety.
Missing Ordered Fall Mat for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a resident assessed as high risk for falls received the physician-ordered fall prevention intervention of a fall mat positioned on the right side of the bed. Resident #50 was admitted with diagnoses including orthostatic hypotension, lack of coordination, reduced mobility, and communication deficit. The resident’s fall risk assessment showed a score of 50, indicating high risk for falling, and the care plan identified the resident as at risk for falls and fall-related injury due to a history of falls with fracture, cognitive impairment, and decreased safety awareness. During multiple observations, the resident was seen at the bedside and no fall mat was present on the right side of the bed or located in the room. The physician order dated 6/7/2026 specified a mat on the right side of the bed, but the MAR and TAR did not reflect the fall mat as an implemented intervention. The resident stated the fall mat had been removed after a new bed was placed and had been gone for a long time. An RN stated the resident was a fall risk and that the order for the fall mat should be followed or cancelled if no longer needed. The DON stated the bed had been changed out and the mat would get in the way, and the order should have been cancelled.
Smoking Safety Interventions Not Followed
Penalty
Summary
The facility failed to ensure adequate assessment and implementation of smoking safety interventions for four sampled residents who smoked. Residents #12 and #85 were observed smoking in the designated smoking area with staff supervision on multiple occasions, but neither was observed wearing a smoking apron even though the smoking binder and care plan indicated they needed one. During an interview, the ADON confirmed both residents were listed as needing aprons and stated the residents sometimes complained about the apron, but they should not smoke unless they put it on. The ADON also stated he does not go out with smokers often and does not know when assessments are completed. Resident #12 had diagnoses including COPD, muscle weakness, and epilepsy, and smoking evaluations noted tobacco use and balance problems while sitting or standing; smoking was added to the care plan with a clothing protector intervention. Resident #85 had diagnoses including hemiplegia and right-hand contracture, and although initial smoking evaluations indicated tobacco use with no impairments, smoking was later added to the care plan with a clothing protection requirement. Resident #52, who had CVA with right-sided weakness and paralysis, diabetes, mood disorder, major depressive disorder, and right hand and upper arm contracture, was observed smoking in a wheelchair without a smoking apron despite a care plan intervention requiring one. Resident #11, who had TBI, schizoaffective disorder, major depressive disorder, paraplegia, and upper extremity contractures, was also observed in the smoking area in a wheelchair without a smoking apron, and no attempt was made by the smoking monitor to get the apron on. The DON confirmed that Residents #52 and #11 were supposed to wear smoking aprons when smoking, and the facility smoking policy required residents to be educated and evaluated for smoking upon admission, re-admission, and quarterly.
Failure to Use Required Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to ensure Resident #5 was transferred with a mechanical lift as required. Resident #5 was admitted with diagnoses including cerebral palsy, BPH, and hypertension, and a quarterly MDS showed severe impairment in thinking with a BIMS score of 4. He required substantial to maximal assistance with toileting hygiene, used a wheelchair for mobility, and his care plan documented a history of falls with interventions initiated for a mechanical lift for all transfers to wheelchairs. A POC task also indicated he required a mechanical lift for transfers every shift, and he was listed among residents requiring a sling/mechanical lift. During observation, CNA C provided incontinent care and transferred Resident #5 from his specialized wheelchair to the bed and back without using a mechanical lift. Instead, she manually lifted him by placing her arms around his upper back and interlocking her fingers. In interview, CNA C stated she had been employed for a month, had completed lift competency during orientation, but did not use the lift because she felt comfortable transferring him without assistance and had never used the mechanical lift on him, although other staff did. The DON stated Resident #5 required a mechanical lift for all transfers and that staff could see this in the POC. The facility policy stated mechanical lifting devices shall be used for lifting and moving residents when necessary.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident elopement for a resident who was identified as at risk for elopement and did not reside on a secured unit. The resident had diagnoses including hemiplegia, diabetes, and dementia, and the MDS indicated cognitive impairment. The record showed multiple elopement evaluations with changing results, including several assessments that identified the resident as at risk for elopement in July 2026, while earlier assessments had indicated not at risk or were incomplete. The care plan identified the resident as an elopement risk/wanderer related to impaired safety awareness, but the record contained only one incomplete intervention related to wandering, and no resident preferences were included. Behavior monitoring documented exit-seeking and wandering behaviors on multiple occasions in May, June, and July 2026, but progress notes did not document the behaviors noted on 5/21/26, 6/21/26, and 7/14/26. A physician order for a Wanderguard was created after the resident was found wandering outside on the curb, and staff notes described discussions with family and assessments after the resident was returned to the unit. The resident was later involved in additional elopement-related events. Staff statements and progress notes described the resident being found near a door, in the front hall, in the assisted living area, and off the unit near common areas, with staff searching for her after she was reported missing. One note stated the resident could escape through a security door because the alarm was broken and had not been fixed yet. Another investigation note stated the resident was found off the unit in a common area adjacent to the unit after being let off by an unknown visitor. The facility determined that the resident was cognitively unable to recognize the door requiring a code and would be physically unable to open it without assistance. The report states the facility was out of compliance with resident safety and supervision since 4/12/26.
Failure to verify correct sling size and safe lift use during resident transfers
Penalty
Summary
The facility failed to ensure staff followed accident prevention interventions and safe device use for three sampled residents who required total body lift transfers. The report states that four certified nursing assistants did not verify the correct sling size before transferring residents, despite care plans and the lift’s sling-size identification system directing staff to use specific sling sizes based on resident weight and transfer needs. Resident 39 had severe cognitive impairment, Alzheimer’s disease, dementia with behavioral disturbance, anxiety disorder, and muscle weakness. Her care plan and mobility assessments showed a progression from sit-to-stand lift use to total body lift use with two staff members and a medium sling. On 5/1/26, she was transferred from her wheelchair to her bed by a CNA using a sit-to-stand lift when the sling strap came loose from the hook on the lift and the chest strap clip broke, causing her to fall backward onto the floor. She sustained a skin tear on her right forearm, bruising to the right side of her face, redness to the right side of her body, and a bruise on her right frontal scalp. She was sent to the ER, where X-rays showed no acute findings or fractures. Observations later showed resident 39 being transferred with a total body lift using a large sling, and resident 8 and resident 25 were also observed with large total body lift slings on. Resident 8 had paraplegia, moderate cognitive impairment, and a care plan directing total body lift transfers with a medium and extra-large sling, while his mobility assessment indicated an extra-large sling and two staff members. Resident 25 had vascular dementia and muscle weakness; her care plan directed total body lift transfers with two staff members, and her mobility assessment indicated a large sling. Interviews with CNAs showed that staff sometimes relied on the sling already in the room or judged sling size by how it fit, rather than consistently referring to the care plan or Kardex. The DON and MDS coordinator stated that staff were expected to use the resident’s care plan or Kardex to determine sling size for safe transfers.
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