Failure to Ensure Safe Transfer and Timely Assessment After Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to appropriately transfer a resident with multiple complex medical conditions, including dementia, morbid obesity, and active chemotherapy treatment. The resident was identified as a high fall risk, but the facility did not assign a total score on the Fall Risk Evaluation to indicate the resident's risk level. Additionally, recommendations from a recent physical therapy evaluation, which specified the use of a mechanical lift for transfers, were not implemented in the resident's care plan or orders. On the day of the incident, multiple nursing assistants attempted to transfer the resident from bed to wheelchair without a gait belt and did not use a mechanical lift, despite the resident expressing pain and inability to stand. The staff made three attempts to transfer the resident, during which the resident's leg became twisted and the resident was lowered to the floor. After the fall, the staff used a mechanical lift to move the resident to a wheelchair, but a thorough assessment, including range of motion, was not conducted by a registered nurse prior to the transfer. The resident continued to complain of pain, but was sent to a scheduled medical appointment, where further symptoms were noted and the resident was transferred to the emergency department, where a significant leg fracture was diagnosed. The facility also failed to notify the resident's physician of the fall and injury in a timely manner. The physician was not informed until the hospital contacted the facility the following day. Interviews with staff and leadership confirmed that standard transfer procedures, such as the use of a gait belt and mechanical lift, were not followed, and that communication regarding changes in the resident's condition and care needs was inadequate. The facility did not have a transfer policy available for review.