Failure to Prevent Accidents and Ensure Safe Transfers
Penalty
Summary
The facility failed to provide adequate supervision and accident prevention for three residents reviewed for falls. One resident, who had a history of falls, generalized weakness, and required substantial assistance for mobility and toileting, experienced a fall outside the facility during transport to a medical appointment. The resident, who was known to have diarrhea and was on a blood thinner, was not accompanied by facility staff as required by his care plan, and did not use his prescribed mobility aids. The fall occurred when the resident attempted to use a restroom at a gas station with only the transport driver assisting, resulting in a head injury and hospitalization. Two other residents experienced falls during transfers using a mechanical sit-to-stand lift. One resident, with moderate cognitive impairment and significant physical limitations, slipped out of the sling during a transfer when the safety features were not properly utilized. Staff interviews revealed a lack of education and awareness regarding the use of a hip sling as a preventive measure, and there was no evidence of follow-up training after the incident. Observations showed that staff did not consistently use the correct sling or ensure that safety straps were properly tightened during transfers. Another resident, who was non-ambulatory and required maximal assistance, was involved in a fall when the sling used with the sit-to-stand lift was not manufactured for use with that specific lift, contrary to the operator's instructions. Staff failed to double-check the straps and did not use all required safety features, resulting in the resident being lowered to the floor after the sling became detached. Observations confirmed that mismatched slings were in use and that staff did not always adjust or tighten safety belts as required. The facility lacked consistent adherence to manufacturer instructions and did not provide adequate staff education or supervision to prevent these incidents.