Failure to Prevent Accident Hazards and Ensure Safe Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. In the first incident, a cognitively intact resident with significant mobility assistance needs experienced an unwitnessed fall while attempting to reach an item from the bedside table. After the fall, the resident was found on the floor, expressed pain, and refused the use of a mechanical lift for transfer. Despite showing signs of injury and vocalizing pain, staff, including agency CNAs, manually lifted the resident by the arms and legs to return them to bed, without performing a full assessment or obtaining vital signs. The resident later was found to have sustained fractures to the left humerus and femur, with ongoing complaints of pain and repeated refusals for hospital transfer until eventually agreeing to be sent out for further care. Interviews with staff and the resident confirmed that the transfer was performed without the use of a mechanical lift, contrary to facility policy, and that the resident's pain was not adequately assessed prior to movement. Staff present at the time, including agency personnel, did not perform range of motion checks or vital signs, and the nurse on duty failed to call EMS despite the resident's complaints of pain and visible distress. Facility leadership, including the DON and Medical Director, later confirmed that the appropriate response would have been to contact EMS and not move the resident if injury was suspected. In a separate observation, another resident with moderate cognitive impairment, paraplegia, and total dependence for transfers was not transferred safely using a mechanical lift. During a Hoyer lift transfer, staff failed to properly adjust the resident in the sling, did not position the wheelchair correctly, and allowed the resident to dangle and spin in the air without adequate support. Only one staff member operated the lift and attempted to adjust the resident simultaneously, while the other did not provide necessary spotting or support. Interviews with staff and facility leadership confirmed that these actions were not in accordance with the facility's mechanical lift policy, which requires two staff to ensure resident safety and proper technique during transfers.