Failure to Use Transfer Belts and Maintain Hazard-Free Environment Leads to Resident Falls
Penalty
Summary
The facility failed to provide a hazard-free environment and did not utilize required assistance devices, such as transfer belts, as outlined in resident care plans for three of four residents reviewed for falls. One resident with a history of falls, left scapula fracture, and moderate dementia required substantial to maximal assistance for transfers and was care planned for transfer belt use. Despite this, the resident was assisted without a transfer belt and subsequently fell, resulting in visible injuries to the face and head. The resident confirmed that the transfer belt was not used during the incident. Another resident with severe cognitive impairment and a history of fractures was identified as a fall risk and required two-person assistance with a transfer belt. Staff failed to follow the care plan by leaving the bed remote within the resident's reach, which allowed the resident to raise the bed and fall. Observations confirmed the remote was accessible, and staff interviews revealed a lack of awareness regarding the ability to lock the bed remote, contrary to care plan instructions. A third resident with hemiplegia and recent stroke was also care planned for transfer with a belt and two-person assistance. However, staff were observed ambulating the resident without a transfer belt, and the staff member admitted to not using the belt because it was bothersome and unavailable. Interviews with nursing and therapy staff confirmed that the transfer belt was required for safe transfers, and the facility's policy mandated its use for both single and double assist transfers. Family members also reported inconsistent use of transfer belts and adherence to care plans by staff.