Failure to Provide Required Two-Person Assistance During Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's fall prevention policy by not providing the required two-person assistance during a transfer for a resident who was totally dependent on staff for transfers. The resident, an older male with a history of rhabdomyolysis, polyneuropathy, left artificial knee joint, prior falls, and generalized arthritis, was being transferred from a shower table to his bed by a single certified nursing assistant (CNA). The care plan for this resident specifically required the use of a mechanical lift and two-person assistance for all transfers due to his high risk for falls and previous injuries. During the incident, the CNA attempted the transfer alone after being unable to find another aide and forgetting to ask the LPN for help, despite being instructed to do so. As a result, the resident slid off the shower table and fell to the floor, sustaining bruising and acute lower back pain, which was confirmed by hospital evaluation. The resident expressed anxiety and fear of future falls, stating he had previously requested not to be transferred in that manner. Documentation and staff interviews confirmed that the facility's fall prevention policy and the resident's care plan were not followed at the time of the incident.