Failure to Follow Two-Person Transfer Protocol Resulting in Resident Fall
Penalty
Summary
A facility failed to ensure the provision of care and services necessary to prevent a fall and maintain the physical health of a resident with significant medical needs. The resident, who had an above-the-knee right leg amputation, dementia, and a cognitive communication deficit, was assessed as requiring two-person assistance for all transfers according to both physician orders and the Kardex. Despite these documented requirements, a nurse aide transferred the resident alone after asking the resident if he needed one or two-person assistance and relying on the resident's response, rather than following the established care plan. During the transfer, the resident's leg slid, resulting in a fall in the bathroom. The resident experienced pain and swelling in the left ankle, which had not been previously injured, and received pain medication and an x-ray. Facility documentation and a root cause analysis confirmed that the staff member did not adhere to the required two-person assist protocol, directly contributing to the fall. The Nursing Home Administrator verified that the staff member failed to follow established protocols, placing the resident at risk.