Failure to Follow Transfer Interventions Results in Resident Fall
Penalty
Summary
The facility failed to follow established interventions to prevent falls for a resident identified as being at risk. According to the care plan and therapy documentation, the resident was totally dependent for transfers and required the use of a Hoyer lift with two staff assisting. Despite this, staff used a stand-up lift, which was not appropriate for the resident's condition, resulting in the resident sliding out of the lift during a transfer from wheelchair to bed. The incident occurred after a CNA, unfamiliar with the resident's transfer needs, relied on the resident's verbal instruction rather than consulting the care plan or Kardex, as required by facility policy. Interviews with staff and review of records confirmed that the care plan and Kardex clearly documented the need for a Hoyer lift and total assistance for transfers. Both the CNA involved and another CNA admitted they did not check the care plan or Kardex before attempting the transfer. The Therapy Director and DON also confirmed that the resident's transfer method had not changed and that staff are expected to review the care plan or Kardex prior to transferring residents. The failure to follow these documented interventions led to the resident's fall, though no injuries were observed at the time.