Failure to Provide Required Two-Person Assistance During Resident Transfers Resulting in Falls
Penalty
Summary
The facility failed to ensure that residents requiring two-person assistance for transfers were transferred by the appropriate number of staff, resulting in falls and injuries for two residents. In the first case, a resident with a history of a femur fracture, pressure ulcer, and periorbital cellulitis, who was cognitively intact and required two-person assistance for transfers, was transferred by a single CNA from bed to a shower chair. During the transfer, the resident's feet slipped, resulting in both the resident and the CNA falling. The resident sustained an abrasion to the head. The CNA admitted to transferring the resident alone despite knowing the resident required two-person assistance, and did not report the fall to the charge nurse as required by facility policy. The care plan and employee training records confirmed the resident's need for two-person assistance and the CNA's awareness of this requirement. In the second case, another resident with multiple diagnoses including a right arm fracture, muscle wasting, anemia, unsteadiness, blindness, and gait abnormalities, and who was on a blood thinner, was also transferred by a single CNA despite a care plan specifying maximum two-person assistance. During the transfer from bed to wheelchair, the resident fell back and was lowered to the floor by the CNA, resulting in an abrasion to the scalp and a bruise to the forearm. The resident was subsequently sent to the emergency department for evaluation due to head trauma and anticoagulant use. The CNA acknowledged knowing the resident required two-person assistance but did not reference the care plan prior to the transfer. Both incidents were substantiated through interviews with staff, residents, and family members, as well as review of care plans, medical records, and facility policies. The facility's policies required staff to follow care plans and report all incidents and accidents immediately. In both cases, the staff involved failed to follow the established care plans for transfer assistance, directly leading to resident falls and injuries.