Failure to Ensure Safe Transfer and Thorough Fall Investigation
Penalty
Summary
The facility failed to provide a safe transfer and adequately investigate a fall for one resident with moderate cognitive impairment who required substantial to maximal staff assistance for transfers. The resident's care plan indicated a need for moderate assistance and noted behaviors such as resistance to staff, stepping backwards, pulling away, and lowering himself to the floor. On the date of the incident, a Certified Nursing Assistant (CNA) assisted the resident in transferring from bed to wheelchair, during which the resident fell to the ground. There was no documentation in the medical record detailing how the fall occurred, which staff were involved, or whether assistive devices such as a gait belt were used, despite facility policy requiring their use for such transfers. The facility's fall prevention policy required immediate post-fall huddles and thorough documentation, but these steps were not followed. The incident audit report relied solely on nursing notes and did not identify the staff involved or the use of assistive devices. The Quality Assurance/LPN confirmed that gait belt usage should have been documented and that witness statements were missing. The fall investigation was incomplete, and the care plan was not updated with the incident or post-fall interventions, as required by facility policy.