Failure to Ensure Safe Transfer and Assessment After Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to ensure safe transfers and proper assessment for a resident with significant physical and cognitive impairments. The resident had a history of hemiplegia and hemiparesis following a stroke, was dependent for all activities of daily living, and required the use of a Hoyer lift for transfers. The care plan specified that two staff members should be present for Hoyer lift transfers, and that a nurse should assess the resident before moving them after a fall. On the day of the incident, the resident slipped from their wheelchair onto the foot pedals. A nursing assistant attempted to transfer the resident back to bed using the Hoyer lift, but did so without the required assistance of a second staff member. There was no documented assessment by a nurse prior to moving the resident after the fall, as required by facility policy. The incident was later reported to the DON, who then notified the primary care provider and the resident's power of attorney. Following the incident, the resident exhibited increased pain and swelling in the right arm, as documented in pain assessments and progress notes. The facility's investigation confirmed that the transfer was performed by a single staff member and that the required nursing assessment prior to moving the resident after the fall did not occur. Interviews with staff corroborated that the Hoyer lift was used without a second staff member and that the nurse assessment was not completed before the transfer.