Failure to Provide Timely Transfer Assistance Results in Resident Fall and Fracture
Penalty
Summary
A resident with diabetes and end stage renal disease, identified as a fall risk due to medical conditions, lack of safety awareness, and poor impulse control, was not timely assisted with a transfer. The resident's care plan included interventions such as keeping the call light within reach and anticipating needs. On the evening of the incident, the resident used the call light and requested assistance from the night nurse, who was occupied with wound care. After waiting for approximately 45 minutes without staff response, the resident attempted to self-transfer from the bedside commode to the bed, resulting in a fall. Staff interviews revealed that the assigned CNA did not respond to the call light because he had left the facility to search for an eloped resident, and was unaware of the resident's need for assistance. Other staff members were either not aware of the situation or were engaged in other tasks. The resident was found on the floor after the fall, subsequently hospitalized, and diagnosed with a fractured femur. The facility's failure to provide timely assistance and adequate supervision directly contributed to the resident's accident and injury.