Failure to Follow Care Plan Transfer Interventions Results in Resident Falls
Penalty
Summary
The facility failed to provide a safe environment and did not follow fall prevention interventions as outlined in the individual comprehensive care plans for two residents. In one instance, a resident with a history of severe cognitive impairment, traumatic brain injury, and a cervical vertebra fracture required two-person assistance and a neck collar for all transfers. Despite this, a CNA attempted to transfer the resident alone using a mechanical lift, without the neck collar in place. The resident fell, sustained a head laceration requiring emergency hospital transfer, and was admitted for eight days with three staples placed in the occipital area. In another case, a resident with impaired mobility and chronic medical conditions required maximum assistance for transfers, specifically with two staff members and the use of a gait belt and walker. A CNA attempted to transfer the resident alone, resulting in the resident sitting/falling onto the floor. The resident denied injury, but the incident demonstrated that the care plan interventions for safe transfer were not followed. Both incidents were confirmed through review of medical records, care plans, staff interviews, and facility documentation. The facility's own policies required adherence to care plan recommendations and the presence of two staff members for mechanical lift transfers, which was not followed in these cases.