Failure to Implement Fall Prevention and Safe Transfer Interventions
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions and proper transfer techniques for two residents identified as being at risk for accidents. One resident, with a history of falls, chronic pain, and low back pain, was found on the floor after rolling out of bed. Although the care plan and interdisciplinary team (IDT) notes specified the use of a perimeter mattress as a fall precaution, observation revealed that the mattress was not in place. The Director of Nursing confirmed that the perimeter mattress had been moved during room remodeling and was not returned to the resident's room, despite it being a documented intervention. Another resident, diagnosed with osteoporosis and a history of falls, had a physician's order and care plan requiring the use of a sit-to-stand lift for transfers in and out of bed. However, staff failed to use the required lift, resulting in the resident losing strength and balance during a transfer and being assisted to the floor. The IDT review identified that the staff did not follow the prescribed transfer method, and the DON acknowledged that audits were not conducted to ensure other residents were being transferred according to their care plans.