Failure to Ensure Safe Transfers and Fall Prevention
Summary
Staff failed to safely transfer a resident with severe cognitive impairment and bilateral lower extremity functional limitations using a mechanical Hoyer lift. During a transfer to a recliner, staff used a Hoyer lift that was not wide enough to accommodate the recliner, but proceeded with the transfer regardless. As the resident was being lowered, the lift's bar swung back and struck the resident in the forehead, causing a laceration and bruising that required emergency room treatment and sutures. The incident involved both a hospice aide and a facility aide, and it was confirmed that the staff continued the transfer despite recognizing the equipment was not appropriate for the task. In a separate incident, another resident with bilateral below-knee amputations and chronic respiratory failure experienced a fall from bed during routine care. The resident, who was cognitively intact and required substantial assistance with bed mobility, was rolled onto his right side by a CNA working alone, after being unable to find another staff member to assist. The resident rolled out of bed and onto the floor. The fall report was found to be inaccurate, and the resident was not interviewed about the incident. The nurse on duty did not assess or interview the resident following the fall, and the fall investigation report was incomplete. Both incidents demonstrate failures in providing adequate supervision and assistance devices to prevent accidents, as well as failures in thoroughly investigating and accurately documenting resident falls. The facility's policies required staff to ensure resident safety during activities of daily living and to identify interventions related to specific fall risks, but these were not followed in the cases described.
Plan Of Correction
What corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident #19 has been assessed and evaluated for appropriate transferring techniques, per facility policy, on multiple dates (note attached audit of completion). Through ongoing assessment, resident has been transferred, with no difficulty, and without injury obtained. Patient denies any concerns/discomfort with transferring techniques concluded. The oversized recliner was removed prior to survey initiation, per family request. Hospice provider has been advised to provide ample amount of time/notification for DME changes/removal to allow for appropriate transition of resident. Resident #25 has been interviewed for bed mobility preferences. Resident states he prefers to be a two person assist despite his ability to complete tasks with one individual. Resident's plan of care has been updated to identify specifics of patient preference (note attached). Facility staff educated on change of care, same date (included for reference). How will you identify other residents having the potential to be affected by the deficient practice and what corrective action will be taken: Managerial personnel will conduct random audits of bed mobility tasks and transfer completion guided per each individual's plan of care. Audits will be assessed daily, on each unit, at random time intervals x 1 week, twice weekly x 2 weeks, and once per week x 4 weeks. If concerns are identified, those individuals will be re-educated of the facility's transfer policy and procedures with hands-on guidance to be done. Initiation of a Performance Improvement Plan will be conducted, as needed. What measures will be put into place or what systemic changes will you make to ensure the deficient practice does not recur: Upon admission, each resident shall be assessed for safe transfers/bed mobility tasks guided per the functional status and personal preference expressed. Activities of daily living will be re-assessed quarterly, as needed, and with any significant medical changes following the initial admit, per facility designee, and will be reflected on the individualized plan of care. How the corrective actions will be monitored to ensure the deficient practice will not recur, ie., what quality assurance program will be put into place; and dates when corrective action will be completed: This plan of correction will be implemented, and the corrective action will be evaluated for its efficiency. The plan of correction is integrated into the facility's Quality Assurance Program. All auditing tools will be completed, as dictated, with thorough review. Any adverse findings/trends noted will be corrected immediately and brought to the Quality Assurance and Performance Improvement Committee for review. Please consider this plan of correction to be an allegation of compliance as if 07-18-2025. Resident #19's most recent assessment was done on 07/18/2025, which was completed by nurse on the unit. Hospice nurse was notified the date of the incident, which was 06/06/2025. The Director of Nursing, unit managers, and maintenance director reviewed wheelchairs and personal chair sizes to ensure mechanical lifts meet manufacturer guidelines when in use. No concerns were identified, and audit was completed the week of survey. Mechanical lift inspections are done monthly by the maintenance director. Maintenance Director reports any adverse findings to the Director of Nursing. A thorough investigation was completed per interdisciplinary team on 04/14/2025, which included Director of Nursing, Unit Manager, and MDS nurse. Initial interview incident was conducted per agency nurse at time of fall. Subsequent communication completed on 04/14/2025 per Unit Manager. In clinical care meeting on 04/14/25, resident #25 incident reviewed including preference stated by resident and during that time resident did not express any concerns with changes in the plan of care. During plan of correction review, resident was reinterviewed and expressed the desire to have two staff assist during bed mobility this time forward, which was 07/22/25. Plan of care updated with the following information. Yes, each fall investigation is led by the Director of Nursing and reviewed with the clinical team. The new processes were put into place and the implementation of the IPRO fall tracking tool alongside current facility policy and procedures for incident investigations. The licensed nurses and STNA are educated on transferring techniques including Hoyer lift policy and procedure at time of hire, annually, and with any manufacturer changes or new equipment. Upon hire would be our HR representative, annually or any changes would be completed by managerial nursing staff. Maintenance Director supplies any information regarding new lifts introduced into the facility. All nurses are oriented upon hire regarding risk management completion, interviewing staff/obtaining witness statements, and interviewing residents when applicable regarding cognition. In specific to this incident, agency staff was reeducated on thorough investigation; however, per risk management completion, it appears incident review was conducted accordingly. Director of Nursing reviews and signs each risk management. If concerns are identified, the Director of Nursing does a one-on-one reeducation with the staff member. Yes, all audits observed will include Hoyer transfers guided per resident’s individual plan of care. Yes, all falls are investigated to ensure thoroughness, including resident/staff interviews as applicable. Director of Nursing reviews with clinical staff. Every fall is reviewed and will continue to be reviewed indefinitely. Yes, it is the facility's utmost opinion that a thorough investigation was concluded on 04/14/2025 following the fall of resident #25. The initial interview of the incident was concluded immediately per agency nurse at the time of fall. Subsequent communication was completed, post ED return, per unit manager 04/14/2025. The new IPRO fall tracking tool was initiated 07/08/2025. The IPRO tracking tool has been utilized for all falls in July 2025. This new process will continue indefinitely. Yes, all staff (nurses and CNA's) have been educated on the proper transferring techniques, via Hoyer lift, post survey initiation and the AOC date, conducted per managerial nursing staff beginning 07/02/2025 through survey completion. Yes, all nurses have been re-educated on thorough fall investigation completion to include interviewing residents and staff (as applicable) after the survey start and prior to the AOC date. This guidance was transcribed per Director of Nursing and expressed to staff per nurse managers. The agency nurse was provided appropriate policy and procedure guidelines for incident/progress note completion on 04/14/2025 directly via the agency portal.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to ensure effective fall alarms and supervision: two residents had Smart Caregiver monitoring devices set to LOW volume, and one resident's bed alarm did not alert staff before the resident was found on the floor after an unwitnessed fall. One resident had dementia, osteoporosis, prior TIA, and cognitive impairment and was fully dependent on staff, while staff also found that a second resident's bed and recliner alarms did not activate properly during testing.
Failure to assess the safety of perimeter mattresses for two residents. Both residents had severely impaired cognition and significant mobility limitations, and both care plans included use of a perimeter mattress to define the edges of the bed. However, their Mobility, Physical Device, and Fall Risk assessments lacked documentation of a perimeter/defined edge mattress assessment. Staff interviews showed inconsistent understanding of the required order, IDT review, engineering review, and safety assessment before use.
Improper Mechanical Lift Transfers: A resident with dementia, spinal cord dysfunction, and dependence for transfers was supposed to be moved with a full-body mechanical lift and two staff members, but a TMA stated she transferred the resident alone. The resident reported that staff sometimes used only one person for lift transfers because of staffing shortages, while other staff and the DON stated this was unsafe and against policy.
Two residents were involved in accident-hazard deficiencies. One resident with cancer, PVD, and Alzheimer’s disease was observed in a wheelchair with feet extending past short footrests, with the lower legs resting against the hard footrests despite a care plan entry for padding. Another resident with dementia and a hx of falls had an unwitnessed fall, but ordered orthostatic BP monitoring was not completed accurately and staff reported no post-fall PT referral was received.
A resident was given a new electric wheelchair without a prior therapy assessment and could not stop the chair, causing it to strike a bed frame and resulting in a leg laceration, tibia/fibula fractures, and a syncopal episode from blood loss. Another resident with cognitive impairment and high fall risk continued to self-transfer and fall, but the care plan was not updated with new fall interventions after repeated incidents.
A CNA used a Hoyer lift alone to weigh one resident, and another CNA was observed using a Hoyer lift alone to weigh a second resident. One resident’s care plan called for a 2-assist Hoyer lift, and the facility’s lift competency checklist and policy both required two caregivers for mechanical lift use; the DON and Director of Therapy also stated that two staff members are always required.
Failure to Ensure Effective Fall Alarms and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and effective use of assistive fall-prevention devices for two residents who were reviewed for fall precautions. One resident had diagnoses including unspecified dementia, age-related osteoporosis, a history of transient ischemic attack, and cognitive impairment, and was described by the POA as weak, bedbound, and unable to participate in physical therapy after a prior right femur fracture. The resident was completely dependent on staff for eating, hygiene, mobility, and toileting, and the care plan included a bed alarm per orders. The resident was found on the floor next to the bed after an unwitnessed fall. The POA reported receiving a call from the facility that the resident had been found on the floor and was not injured, and stated the resident frequently forgot to ask for help and had tried to get up without assistance before. A nurse stated the bed alarm was not heard when the resident fell, and the facility was unable to provide evidence that the bed alarm functioned as intended or alerted staff before the resident was found on the floor. The event report identified the fall as unwitnessed and did not indicate that a bed alarm alerted staff. The facility also failed to ensure the Smart Caregiver sensor pad monitoring system used for another resident was functioning properly and set at an audible volume. Two Smart Caregiver monitor boxes at the nurses' station for that resident's bed and recliner were observed set to LOW volume, and the chime settings faced the back wall of the desk. When a CNA tested the recliner alarm from the resident's room, the monitor at the nurses' station did not illuminate or sound an alert on either attempt. The CNA changed the batteries but did not retest the device, and both CNAs stated they could hear alarms only if they were near the nurses' station and did not recall training on operation or testing of the devices. The facility director stated the facility did not perform preventive maintenance on the devices and relied on staff to ensure they functioned properly.
Failure to Assess Safety of Perimeter Mattresses
Penalty
Summary
The facility failed to ensure that 2 residents with perimeter mattresses were assessed for safety. One resident had a significant change MDS showing severely impaired cognition, dementia, reduced mobility, muscle weakness, and need for assistance with bed mobility, sitting, standing, and transfers. That resident’s care plan identified limited physical mobility related to dementia with mood disturbance and anxiety, a genetic muscle disorder, spinal stenosis, and osteoarthritis, and included use of a perimeter mattress to help find the edges of the bed for bed mobility. However, the resident’s Mobility, Physical Device, and Fall Risk assessment lacked documentation of an assessment for a perimeter/defined edge mattress. The second resident’s annual MDS showed severely impaired cognition, dementia, multiple sclerosis, repeated falls, and need for partial to moderate assistance with bed mobility. The care plan identified limited physical mobility related to weakness, falls, incontinence, hypertension, renal disease, dementia, MS, depression, and delusional disorder, and included use of a bariatric sized bed with a perimeter mattress to define the edges of the bed. That resident’s Mobility Physical Device and Fall Risk assessment also lacked documentation of an assessment for a perimeter/defined edge mattress. During observation, the resident was in bed asleep with a perimeter mattress. Staff interviews showed differing understanding of whether a physician order, assessment, IDT review, engineering review, and safety assessment were required before use of a perimeter mattress, and the DON confirmed both residents’ most recent assessments lacked documentation of a perimeter/defined edge mattress assessment.
Improper Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure transfers were performed according to R24’s assessed needs, care plan interventions, and facility policy. R24’s records showed she had diagnoses including non-traumatic spinal cord dysfunction, diabetes, dementia, depression, heart failure, and asthma. She was dependent on staff for toileting and transfers, was frequently incontinent of bowel and bladder, and had care plan directions for assistance with transfers using a full-body mechanical lift and two staff members. During interviews, a TMA stated she transferred R24 with the full-body mechanical lift by herself because R24 needed to use the bathroom and she felt the transfer was safe. R24 stated staff sometimes transferred her with only one staff member and said they told her there was not enough staff. Other staff interviewed stated transfers with the full-body mechanical lift using one staff member were unsafe and should not occur. The facility policy for using a mechanical lift stated that at least two trained associates are needed to safely move a resident with a mechanical full-body floor-based lift or ceiling/overhead full-body lift.
Unsafe Wheelchair Fit and Incomplete Post-Fall Monitoring
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. Resident 27 was readmitted with diagnoses including cancer, peripheral vascular disease, and Alzheimer's disease and was sometimes able to make needs known. On multiple observations, Resident 27 was seated in a slightly tilted back wheelchair with feet extending beyond the footrests, and the back of the lower legs rested against the hard footrests above the ankle/heel area. A pillow was observed either on the floor or behind the legs rather than padding the footrests. The focused care plan for skin integrity included padding to wheelchair footrests, and staff interviews confirmed the footrests were too short and needed adjustment or replacement, but staff had not notified therapy or otherwise addressed the wheelchair fit. Resident 50 was admitted with diagnoses including dementia, history of falls, and UTI and was sometimes able to make needs known. The care plan identified the resident as at risk for falls. After an unwitnessed fall in the 300 hallway, the incident investigation added interventions to monitor orthostatic blood pressures and refer to physical therapy. However, the record showed an orthostatic blood pressure order on 05/20/2026 was not completed, and subsequent orthostatic blood pressures recorded the same blood pressure and pulse for all three positions on 05/22/2026, 05/23/2026, and 05/24/2026. Staff later stated they had not received a post-fall therapy referral, and the DNS stated the resident should have had orthostatic blood pressures taken accurately to rule out orthostatic hypotension.
Failure to assess electric wheelchair use and update fall interventions
Penalty
Summary
The facility failed to comprehensively assess a resident for the use of an electric wheelchair and failed to develop new interventions to reduce fall risk for another resident. The report states that the facility’s policies required a device evaluation before an electric wheelchair was initiated, resident education and consent, and an updated service plan identifying device use and other interventions. The fall management policy required individualized care plan updates, a systematic review after each fall, identification of root cause, and review of prior interventions when new interventions were implemented. Resident 73 was admitted with weakness and lymphedema and had an above-the-knee left leg amputation, requiring assistance with bed mobility, transfers, and locomotion. The resident’s record showed cognitive intactness, lower extremity impairment, supervision or touch assistance for bed-to-chair transfers, and use of a manual wheelchair. On 4/17/26, a newly issued electric wheelchair was delivered and the resident was assisted into it. The resident reported that the representative showed how the chair worked but not enough, and that the resident did not know how to stop it. The resident then returned to the room, could not stop the chair, and the chair continued forward into the bed, causing the resident’s right leg to strike the metal bed frame. The resident sustained a five-centimeter laceration to the right anterior lower leg, fractures of the right tibia and fibula, and a brief syncopal episode secondary to blood loss. The resident also received an anticoagulant, which contributed to significant bleeding. The clinical record contained no evidence that the resident had been assessed to safely operate the electric wheelchair before use. Resident 3 was admitted with a right total hip replacement with deep hardware removal and post-traumatic osteoarthritis of the right hip. The resident had a high fall risk on Morse Fall Scale assessments, cognitive impairment on OT evaluation, and a PT evaluation showing a score of zero on the Short Physical Performance Battery, indicating high fall risk and increased risk of mobility disability. The resident fell on 3/31/26 after getting up independently and sustained a right femur fracture requiring surgical repair, and fell again on 5/12/26 after getting up independently and sustained a skin tear to the right elbow. The care plan identified fall risk and included reminders to use the call light, non-skid socks, and one-person assistance for toileting and transfers, but revisions to the care plan did not add new or amended fall prevention interventions. Staff statements indicated the resident continued to self-transfer and toilet without assistance, staff believed the resident was independent, and the existing fall prevention interventions were ineffective.
Unsafe One-Person Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure safe use of a mechanical lift for 2 of 3 residents reviewed for accidents. During an observation on 6/2/2026 at 8:42 AM, Resident #4 was lying on his bed on top of a Hoyer pad while CNA Staff K stood on the right side of the bed with a mechanical lift; the lift hand bags were observed over the resident, and no other staff member was in the room. Staff K stated that he was weighing Resident #4 and that normally only one person uses the Hoyer lift for weights, although the resident’s care plan documented a Hoyer lift with 2 assist. On 6/4/2026 at 10:15 AM, CNA Staff D was observed using a Hoyer lift alone to obtain Resident #13’s weight, with the resident lifted approximately 12 inches off the mattress in the sling and no other staff present. Staff D stated that he was performing weekly weights and most of the time did the weights using the Hoyer lift by himself. Resident #13’s MDS Section GG coded the resident as dependent, and the facility’s mechanical lift competency checklist stated that two caregivers are present, while the facility policy for using a mechanical lifting device stated that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The DON and Director of Therapy both stated that a mechanical lift should always be used by two staff members.
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