Failure to Implement Safety Interventions During Toileting Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement appropriate safety interventions for a resident identified as being at moderate risk for falls. The resident, who had impaired mobility and poor sitting/standing balance, was transferred to the toilet using a sit-to-stand mechanical lift. During personal hygiene care, the Certified Nursing Assistant (CNA) removed the lift sling and raised the enabler bar to provide more room, leaving the resident unassisted on the toilet. The resident was unable to maintain posture and balance, resulting in a fall to the floor. The facility's policies required that the harness safety strap be securely fastened and that the resident be properly supported during transfers and toileting. However, the CNA unhooked the resident from the lift and did not reapply the top harness before attempting to move the resident's feet onto the sit-to-stand lift. The CNA confirmed that the resident was unable to balance or stand without assistance, and that the enabler bars were intended for residents who could stand independently. The lack of proper support and supervision directly led to the resident's fall.