Failure to Implement Two-Person Transfer Protocol for Fall-Risk Resident
Penalty
Summary
Facility staff failed to implement assessed interventions to prevent falls for a resident with a history of repeated falls, primary osteoarthritis, and a recent urinary tract infection. The resident's care plan specified the need for assistance from two staff members (Ax2) for all transfers and use of a wheelchair for mobility. Despite this, documentation and interviews revealed that the resident was transferred with only one staff member assisting on at least one occasion, contrary to the care plan requirements. The provider was notified of an incident where the resident was transferred with only one staff member, and the resident reported experiencing a fall in the bathroom a couple of days prior, resulting in pain in the right arm and shoulder. Observation further confirmed that the resident was transferred from the bed to a chair with only one staff member assisting, despite the presence of both an occupational therapist and a nursing assistant in the room. Interviews with staff confirmed that the resident should have been transferred with two staff members, and that this protocol was not followed during the observed transfer. These actions demonstrate a failure to provide adequate supervision and implement fall prevention interventions as assessed and documented in the resident's care plan.