Failure to Follow Transfer Protocols Resulting in Resident Fall and Fatal Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple comorbidities, including dementia, osteoporosis, and a history of fractures, was not transferred according to her care plan requirements. The resident's care plan specified that she required two-person physical assistance and the use of a full body mechanical lift device for all transfers and bed mobility due to her high fall risk and extensive assistance needs. Despite these documented interventions, a CNA attempted to transfer the resident alone, during which the resident's knees buckled, and she was lowered to the floor, resulting in a fall. Following the fall, the resident sustained a skin tear to her right elbow and began to complain of pain in her left leg the next day. Initial x-rays did not reveal any fractures, but the resident continued to experience pain and decreased mobility. The resident was under hospice care, and pain management was provided as the primary intervention. The resident's condition deteriorated, and she passed away several days after the fall. An autopsy later revealed a right femoral neck fracture, deep vein thrombosis, and pulmonary thromboembolism, which were determined to be consequences of the fall and contributed to the resident's death. Interviews with facility staff confirmed that the resident should not have been transferred by a single staff member, as her care plan required two-person assistance and mechanical lift use. The failure to follow the established care plan and provide adequate supervision and assistance during transfers directly led to the resident's fall and subsequent fatal injury.