Inadequate Supervision During Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision during a transfer for one of six residents, resulting in a fall. The resident, who was admitted to the facility with diagnoses including a right fibula fracture, anxiety, and depression, had physician orders indicating that toilet transfers should be completed with the assistance of two staff members. However, during a transfer to the commode, the resident slipped and fell, hitting the back of her head on a railing. Although no bleeding or lumps were noted, subsequent medical evaluations revealed an impacted proximal humerus fracture. The incident occurred when a Nurse Aid (NA) was transferring the resident alone, contrary to the prescribed assistance level. The NA's statement indicated that the resident slid while the NA was moving the wheelchair, and although the fall was partially broken, the resident still sustained injuries. The NA involved in the incident is no longer working at the facility and did not respond to follow-up communications. The Nursing Home Administrator confirmed the facility's failure to provide adequate supervision during the transfer, which led to the resident's fall.
Plan Of Correction
1) 12/30/24 R1 transfer status was reviewed with CNA's and Charge Nurses on R1 Nursing Household by Clinical Nurse Manager/DON. The CNA that was involved in the incident was interviewed, sent home, and terminated from the facility. 2) 12/31/24 Education was initiated by Clinical Coordinator/Designee to Charge Nurses and CNA's on all shifts regarding the transfer status, weight bearing status, resident profile, and Physician transfer orders. 3) 12/31/31/24 CNA's and Charge Nurses on each Nursing Household were interviewed by Clinical Nurse Manager/DON on the current transfer status order of each resident. 4) The Charge Nurse/Designee will monitor between the three shifts five residents on each nursing household for adequate supervision to ensure transfer status orders are being followed three times a week for three months or until substantial compliance is met.