Failure to Provide Adequate Supervision and Assistance During Resident Transfer Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with Parkinson's disease, depression, and anxiety, who was at risk for falls, did not receive adequate supervision and assistance during a transfer. The resident's physical therapy evaluation indicated a need for contact guard assistance for transfers, and the admission Minimum Data Set (MDS) documented a requirement for supervision or touching assistance. However, the resident's care plan did not specify the required level of transfer assistance, and the nursing assistant care sheet indicated assist of one with a gait belt and walker. On the day of the incident, the resident was being assisted in her room by a nursing assistant who placed a gait belt on her and allowed her to stand near the nightstand to brush her hair. The nursing assistant then left the resident unattended to retrieve her walker. During this time, the resident attempted to turn, became entangled with the nightstand, lost her balance, and fell, resulting in a right femur fracture. The staff member was not within close reach to prevent the fall. Interviews with staff confirmed that the resident was supposed to be assisted by one staff member with a gait belt and walker for transfers and ambulation, but the care plan had not been updated to reflect this until after the fall. The facility's fall management policy required interventions to be implemented through a resident-centered plan of care, but the lack of clear documentation and failure to follow the established plan of care contributed to the incident.