Failure to Provide Adequate Supervision During Resident Transfer Resulting in Fall
Penalty
Summary
A certified medication aide (CMA) failed to provide adequate supervision to prevent a fall for one resident who required staff assistance for transfers. According to facility policy, staff are expected to implement interventions based on residents' specific risks to prevent falls. The resident involved had intact cognition and required physical support from staff for transfers, as documented in their assessment. On the day of the incident, the CMA was assisting the resident back from the bathroom but turned away to close the bathroom door, completely letting go of the resident. During this moment, the resident fell to the floor, as confirmed by both the CMA and a witness. Following the fall, the resident complained of hip pain and was transferred to a local hospital for evaluation, though no injuries were ultimately found. The resident's transfer status was subsequently elevated from a one-person to a two-person transfer, and pain medication was prescribed for reported pain. Interviews with the CMA and the ADON confirmed that the CMA should not have let go of the resident during the transfer and that this action was not in accordance with facility policy or best practice.