Failure to Honor Resident Dignity During Post-Fall Care
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during care provided after a fall. After experiencing two falls in one day, the resident was manually lifted and dragged by staff following the second fall, rather than being assisted with a mechanical lift as per facility protocol. Staff interviews revealed that an LPN instructed CNAs to manually lift the resident, disregarding concerns raised by another nurse about the need for a mechanical lift. Multiple staff members described the resident as unable to bear weight and requiring significant physical effort to be moved, with one CNA stating that the resident was essentially dragged down the hallway and into bed. The Director of Nursing confirmed that, while there was no formal written policy, the facility operates as a no-lift environment and staff are expected to use mechanical lifts after falls. Despite this, the LPN directed staff to manually lift the resident, justifying the action by stating the fall was witnessed and did not require the use of a lift. Staff accounts indicated that the resident was not able to assist in the transfer and exhibited signs of discomfort during the process. The actions taken by staff were inconsistent with established facility protocol and failed to honor the resident's right to dignity and respect.