Failure to Ensure Safe Transfers and Fall Risk Reassessment
Penalty
Summary
Staff failed to perform safe transfers for a resident with significant mobility impairments, despite physician orders requiring the use of a mechanical lift. Multiple video reviews and documentation showed that staff transferred the resident manually or with a gait belt, rather than using the required mechanical lift, even after falls occurred. The resident's care plan and therapy recommendations specified the need for a mechanical lift, and therapy had not cleared the resident for any other transfer method. Staff reported that the resident's representative requested transfers without the mechanical lift, but no documentation indicated that this was approved by therapy or the physician. After the resident experienced several falls, there was no evidence that staff completed new fall risk assessments as required by facility policy. The facility's fall prevention and management policy stated that residents should be reassessed for fall risk after each fall, and the results should be reviewed by the interdisciplinary team (IDT). However, interviews with the DON confirmed that no new fall risk scores were calculated after the resident's falls, and there was no documentation of increased fall risk or updated assessments following these incidents. Additionally, video evidence showed that a CNA operated a mechanical lift while talking on a personal cell phone, which was against facility policy prohibiting personal phone use during work. The facility's policies required two staff for total body lifts and specified that residents unable to be elevated from the floor with minimal assistance should only be lifted using a mechanical lift. Despite these policies, staff did not consistently follow safe transfer procedures or reassess fall risk after incidents, directly leading to the deficiency.