Failure to Ensure Safe Transfers and Implement Fall Interventions
Penalty
Summary
A deficiency occurred when staff failed to provide a safe environment free from accident hazards for a resident with hemiplegia and a history of falls. The resident required two-person assistance and the use of a gait belt for transfers, as documented in her care plan following a previous fall with major injury. Despite these directives, a new CNA transferred the resident alone and without a gait belt after the resident insisted on immediate assistance. During the transfer, the resident lost her balance and fell, resulting in a hip fracture that required hospitalization and surgical intervention. The CNA later acknowledged feeling pressured and not following established protocols due to the resident's insistence and a busy shift. Additionally, the facility failed to implement and maintain new fall prevention interventions for another resident with multiple diagnoses, including cognitive impairment, muscle weakness, and a history of repeated falls. The care plan for this resident included the placement of nonskid strips in the bathroom as a fall intervention following a previous incident. However, observations on multiple occasions revealed that the nonskid strips were not present in the resident's bathroom, indicating that the intervention was not carried out as planned. Interviews with staff revealed inconsistencies in how fall interventions were communicated and implemented. Some CNAs reported relying on nurses for updates about new interventions, while others referenced a communication board, but there was uncertainty about how effectively this information was shared. The facility's own policy required prompt investigation and documentation of accidents and incidents, but the lack of follow-through on care plan interventions and proper transfer protocols contributed to preventable falls and injuries for both residents.