Failure to Implement Safety Measures During Resident Transfers and Cares
Penalty
Summary
The facility failed to implement adequate safety measures and supervision during resident care and transfers, resulting in falls for three residents. One resident with a history of hemiplegia, muscle weakness, and prior falls was being assisted off the toilet by a CNA without the use of a gait belt. During the transfer, the resident lost balance and fell, sustaining a fractured left humerus. The CNA reported not being trained to use a gait belt with this resident and instead sometimes used the waistband of the resident's pants for support. The restorative nurse confirmed that gait belts were not previously required for this resident, despite variable strength due to medical conditions. Another resident with muscular dystrophy, poor trunk control, and high fall risk slid out of a shower chair while being pushed by a CNA. The seatbelt on the shower chair was not properly secured, as the CNA believed it was fastened but it had not clicked into place. The resident did not sustain injuries, but the incident was attributed to the unsecured seatbelt, as confirmed by documentation and staff interviews. A third resident with a traumatic brain injury, gait abnormalities, and dementia fell in the shower area while staff were assisting with dressing. The resident lost balance and slipped on a wet floor, which lacked anti-skid mats or strips. The CNA assisting the resident did not place a towel or any non-slip surface on the floor prior to the resident standing, and the resident was not wearing socks or shoes at the time of the fall. The resident sustained a superficial abrasion as a result.