Failure to Provide Required Supervision During Transfer Results in Resident Fall
Penalty
Summary
Staff failed to provide the required level of supervision during a transfer, resulting in a fall with injury for a resident. The resident, who had diagnoses including cerebral infarction, vascular dementia, and anxiety disorder, was assessed as having severe cognitive impairment and was dependent on staff for all activities of daily living, including bed mobility. The care plan specified that two or more staff were needed to assist with bed mobility and peri-care due to the resident's deficits and high fall risk. Despite these documented needs, a CNA performed peri-care alone and rolled the resident onto his side, which led to the resident rolling out of bed and falling to the floor. The resident sustained a skin tear to the right elbow and bruising to the forehead, requiring hospital evaluation before returning to the facility. The facility's policy required care plans to address ADL needs and provide appropriate physical care, but this was not followed in this instance.