Failure to Provide Adequate Supervision During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic subdural hemorrhage, aphasia, left-sided hemiplegia, glaucoma, and cognitive communication deficit was not adequately supervised during a transfer. The certified nursing assistant (CNA) was providing morning care and had positioned the resident on the side of the bed in preparation for transfer. While the CNA turned to retrieve the wheelchair, the resident reached for an item on the floor, lost balance, and fell forward, striking their head on the nightstand and then the floor. The incident was witnessed by the CNA, who reported being one to two feet away and momentarily distracted while setting up the wheelchair in front of the resident. The resident sustained a laceration to the left side of the forehead with moderate bleeding and was subsequently hospitalized. Medical evaluation revealed a small subdural hematoma and a small hemorrhagic contusion to the left frontal lobe. The resident was admitted for monitoring and further evaluation, including imaging studies that confirmed the injuries. The resident's care records indicated a history of left-sided weakness and moderate cognitive impairment, requiring substantial assistance with bed mobility and transfers. The care plan and therapy notes documented the resident as a fall risk due to impaired mobility, cognitive deficits, and a history of stroke. Review of the facility's fall risk assessments revealed inconsistencies and errors in scoring, with one assessment incorrectly indicating the resident was not at high risk for falls. The resident's care plan prior to the incident included interventions for fall prevention, but the supervision provided during the transfer was insufficient to prevent the fall. Staff interviews confirmed that the resident had a known behavior of reaching for objects, which was not adequately addressed during the transfer process.