Failure to Implement and Monitor Fall Prevention and Safe Transfer Interventions
Penalty
Summary
Staff failed to utilize safe transfer techniques and follow individualized care plans for multiple residents, resulting in an unsafe environment. For one resident with left-sided hemiplegia and a history of stroke, staff did not consistently use two staff members during mechanical lift transfers as required by the care plan and facility policy. Observations showed that the resident's left arm was not properly supported during transfers, and staff confirmed that two-person assistance was not always provided, despite education on this requirement. Several residents at risk for falls did not have their care plan interventions implemented or revised as needed. One resident with severe cognitive impairment and contractures had a mesh stop sign and body pillow ordered as fall interventions, but these were repeatedly not in place during observations. The DON confirmed that these interventions were not consistently implemented after falls. Another resident with dementia and a history of falls was left unattended in their wheelchair without required alarms in place, and staff confirmed that the resident was sometimes left alone despite care plan instructions. Additional deficiencies included a resident who was to be laid down after meals as a fall prevention measure, but this was not consistently done within the expected timeframe. Another resident with a history of falls and high fall risk did not have new interventions implemented after multiple falls, despite care plan reviews and incident reports. These failures to implement, monitor, and revise fall prevention interventions and safe transfer practices directly contributed to the facility's noncompliance with accident prevention requirements.