Failure to Follow Fall Care Plans and Safe Transfer Practices Resulting in Resident Falls
Penalty
Summary
The facility failed to follow fall care plans and ensure safe transfer practices for two residents, resulting in both residents experiencing falls. One resident with quadriplegia and intact cognition was dependent on staff for all activities of daily living and was assessed as a low fall risk. This resident fell from a mechanical lift during a two-person transfer when the lift's strap was not properly secured, and the equipment used was reported by staff to be malfunctioning, with loose or swinging arms and missing safety clips. Staff used the lift despite being aware of its issues, and alternative lifts were unavailable due to dead batteries. The resident experienced pain and bruising on the left side and was later sent to the hospital for evaluation after reporting persistent pain. Another resident with severe cognitive impairment and a high fall risk was involved in an incident where a CNA attempted to move the resident in a wheelchair. The resident was being pushed backwards and grabbed onto a door frame, resulting in a fall to the floor. The CNA did not immediately report the incident as a fall, and initial documentation described it as an "almost fall" with the resident being assisted to the floor. However, further investigation revealed that the resident had actually fallen out of the wheelchair while being moved, contrary to the care plan interventions that required close monitoring and ensuring the resident did not grab stationary objects during transfers. Both incidents demonstrate failures to adhere to established care plans and safe transfer protocols. In the first case, staff used malfunctioning equipment and did not ensure proper mechanical lift operation, while in the second case, the staff did not follow the care plan's guidance for safe wheelchair transfers and failed to report the incident accurately and promptly. These actions and inactions directly led to avoidable falls and injuries for both residents.