Failure to Provide Required Supervision During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to implement required safety measures to prevent a fall for a resident with a high risk for falls. The resident, who had diagnoses including a displaced fractured left femur, Parkinson's disease, and a history of repeated falls, was being assisted with personal hygiene and dressing by a Certified Nurse's Assistant (CNA) who had not previously cared for the resident and had not received a report from the off-going staff or nurse. During care, the resident's upper body was shaking and jerking heavily. Despite recognizing the need for a second staff member and a full body mechanical lift, the CNA proceeded to slide the resident to the side of the bed and placed her in a sitting position without assistance. While the CNA reached for a wipe, the resident jerked again and fell off the bed, resulting in a 3-centimeter laceration to the scalp that required staples for closure. Interviews with facility staff, including the LPN, DON, and the resident's primary care physician, confirmed that facility policy and standard practice required two staff members to be present when positioning a resident with such conditions on the side of the bed prior to transfer, especially when using a sit-to-stand mechanical lift. The CNA's partner was available but was not asked to assist. The resident's records indicated a high fall risk, and the facility's policy required staff to identify and implement interventions to minimize fall risks and complications. The failure to follow these protocols directly led to the resident's fall and injury.