Failure to Implement Comprehensive Fall Prevention and Safe Transfer Practices
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized fall prevention program, resulting in actual harm to multiple residents. One resident, who had a history of falls, impaired mobility, and was undergoing chemotherapy and radiation, was identified as high risk for falls and required one to two staff for assistance with transfers and toileting. Despite these documented needs, a CNA attempted to transfer the resident alone and without a gait belt, leading to the resident's knees buckling and a fall back into the wheelchair. This incident resulted in new compression fractures to the thoracic spine and increased pain. The CNA did not immediately report the fall, and there was confusion among staff regarding reporting requirements and the use of gait belts during transfers. Another resident, dependent on staff for transfers due to severe cognitive impairment and physical limitations, was observed being transferred by two CNAs without the use of a gait belt. The transfer was performed by lifting the resident under the arms from a wheelchair to a recliner, contrary to the care plan and standard safety practices. Both CNAs confirmed that a gait belt was not used during the transfer, despite gait belts being readily available on the unit. A third resident, with a history of fractures and cancer, was at high risk for falls and had specific interventions outlined in the care plan, such as keeping mobility aids and personal items within reach. However, observations revealed that these interventions were not consistently implemented, as the resident's walker and personal items were found out of reach on multiple occasions. The resident experienced a fall resulting in multiple fractures, and staff statements indicated the fall was unwitnessed and interventions were not promptly put in place. The DON acknowledged that interventions were not immediately implemented and that there were gaps in ensuring appropriate fall prevention measures.