Failure to Ensure Safe Transfers and Fall Management
Penalty
Summary
The facility failed to ensure safe mechanical lift transfers and proper fall management for two residents with severe cognitive impairment. In one instance, a resident was transferred by a single CNA using a mechanical lift, contrary to facility policy requiring two staff members. During the transfer, the resident detached the sling from the lift and was subsequently lowered to a reclining wheelchair that was broken and leaning forward, causing the resident to slide out. The CNA admitted to performing the transfer alone due to staff being busy, and the Director of Nursing confirmed that two-person assistance is required for all mechanical lift transfers. Additionally, the facility did not document falls in the medical records, investigate the incidents, or implement post-fall interventions for two residents. One resident experienced two falls that were not recorded in the medical record, and there was no evidence of a root cause investigation or development of post-fall interventions. Staff interviews revealed that alternative approaches or interventions were not attempted during care, and the Director of Nursing acknowledged the lack of documentation and investigation for these incidents.