Failure to Ensure Safe Transfers and Adequate Post-Fall Monitoring
Penalty
Summary
The facility failed to ensure safe transfer practices and adequate post-fall monitoring for two residents, resulting in deficiencies related to accident prevention and investigation. One resident, identified as being at moderate risk for falls, experienced a fall during a transfer from the toilet to a wheelchair using a mechanical lift. The CNA responsible did not position the resident's feet correctly on the lift platform, failed to fasten the safety strap behind the resident's legs, and did not listen to the resident's concerns about foot positioning. This improper technique led to the resident's foot slipping and a subsequent fall to the floor. The care plan required these safety measures, but they were not followed during the incident. Another resident, with a history of falls and multiple risk factors such as impaired balance and weakness, fell while attempting to hang up a phone from her wheelchair, which did not have the brakes locked. The resident sustained a deep laceration to her right elbow, which was not appropriately assessed or monitored according to facility policy and physician orders. The wound was not identified by therapy staff who witnessed the fall until the following day, and there was a lack of documentation of vital signs and wound assessments for the required periods post-fall. The interdisciplinary team did not review the incident until nine days after the fall, and key witness interviews were missing from the investigation. The facility's fall prevention policy required thorough investigation, monitoring, and documentation following any fall, including witness statements, post-fall huddles, and ongoing resident assessments. In both cases, these procedures were not fully implemented, resulting in incomplete investigations and insufficient monitoring of the residents' conditions after their accidents. The failures included not following care plan interventions, not conducting timely and complete assessments, and not ensuring all relevant staff were interviewed as part of the investigation.