Failure to Provide Required Transfer Assistance Resulting in Resident Fall and Neglect
Penalty
Summary
A resident with hemiplegia and hemiparesis affecting the left side, who required moderate assistance for transfers and was dependent on staff for activities of daily living, was not provided the necessary care and services as outlined in their comprehensive assessment and care plan. On one occasion, the resident called for a CNA to assist with transferring from a wheelchair to bed. The CNA instructed the resident to get out of the chair and do it himself, then left the room without providing assistance. The resident, unable to safely transfer independently, attempted the transfer alone and subsequently fell from the wheelchair. The facility failed to implement the resident's At Risk for Falls Care Plan, which required staff to anticipate and meet the resident's needs, ensure the call light was within reach, and encourage its use for assistance. The care plan did not specify interventions for transfer assistance, despite the resident's documented need for moderate help. Additionally, the facility did not follow its own Abuse - Prevention, Screening, & Training Program policy, which defines neglect as the failure to provide necessary goods and services to maintain a resident's well-being and avoid harm or distress. Following the fall, the resident reported pain to the face and emotional distress, and was later transferred to a general acute care hospital for further evaluation. Medical records from the hospital indicated the resident was diagnosed with generalized anxiety disorder and had difficulty ambulating due to musculoskeletal weakness. The incident was reported to facility staff, and interviews confirmed the sequence of events leading to the resident's fall and subsequent injury.