Failure to Maintain Supervision During Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with diagnoses of weakness and dementia, and a moderately impaired cognitive status, experienced a fall during ambulation that resulted in a right clavicle fracture. The resident required the assistance of one person for all transfers, with the use of a gait belt and a two-wheeled walker, as documented in the care plan. On the day of the incident, the resident was being assisted by a CNA while walking from the bathroom to her personal recliner. During the transfer, the CNA let go of the resident's gait belt to pull the resident's chair closer, at which point the resident lost her balance and fell in the bathroom doorway, landing on her right side and hitting her head on the bathroom door. The CNA acknowledged in an interview that she had a lapse in judgment by removing her hand from the gait belt during the transfer, which directly led to the resident's fall and subsequent injury. The Director of Nursing confirmed that the facility's expectation is for staff to maintain their hold on the gait belt while transferring residents. The incident was corroborated by the resident's account, medical record review, and staff interviews.