Failure to Follow Transfer Recommendations Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to follow hospital recommendations regarding transfer assistance for a resident with significant mobility and cognitive impairments, resulting in an accident. The resident, who had a history of multiple vertebral compression fractures and severe cognitive impairment, was assessed by hospital occupational and physical therapists as requiring a two-person assist for transfers and ambulation, with the use of a gait belt and rolling walker. These recommendations were documented in the preadmission records and communicated to the facility prior to the resident's admission. On the day of the incident, a CNA assisted the resident with ambulation to the bathroom using a walker, but did so alone and without a gait belt. The CNA reported that she intended to get additional assistance but proceeded to assist the resident when the resident stood up independently. During the return from the bathroom, the resident's ankle gave way, resulting in a fall and an acute distal tibia fracture. Documentation and interviews confirmed that only one staff member was present during the transfer, contrary to the two-person assist requirement outlined in the hospital's recommendations. Further review revealed that the facility's documentation did not clearly indicate the need for two-person assistance for this resident, and the CNA was unfamiliar with the resident's specific transfer needs. The facility's policies required the use of appropriate techniques and devices for resident safety, but these were not followed in this instance. The incident resulted in the resident sustaining a significant injury due to inadequate supervision and failure to implement recommended safety precautions.