Failure to Ensure Safe Transfers and Timely Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when a resident, who was care planned and ordered to be transferred with the assistance of two staff members due to instability and a history of falls and fractures, was transferred by only one CNA. The CNA admitted to transferring the resident alone because the facility was short-staffed, resulting in the resident's left foot becoming caught in the wheelchair wheel and a subsequent fall back onto the bed. The resident sustained swelling, bruising, and was later diagnosed with an acute on chronic distal tibial fracture. The CNA did not immediately report the fall to nursing staff, and the injury was only discovered when therapy staff assessed the resident for therapy later that morning. The care plan was not updated promptly to reflect the new transfer status (mechanical lift) after the incident. Another deficiency was identified regarding a second resident with a history of falls and cognitive impairment. After experiencing two unwitnessed falls, the resident's care plan was not updated with progressive interventions to prevent future falls until several days later. There was also a discrepancy in the documentation dates for when new fall prevention interventions, such as a scoop mattress and low bed, were implemented. Staff were unable to clarify when these interventions were actually put in place, and there was confusion regarding the accuracy of the electronic medical record. The facility lacked a clear policy on following physician's orders for transfer status, and some staff were unaware of where to find residents' transfer requirements. This contributed to improper transfers and delayed implementation of necessary interventions to prevent further accidents. The failures resulted in injury to one resident and inadequate fall prevention measures for another.