Failure to Follow Post-Fall Assessment and Safe Transfer Protocols
Penalty
Summary
Staff failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall from a bath chair. The facility's policy required that after a fall, the resident should not be moved and a licensed nurse must perform a full-body assessment to determine injury before any transfer. However, after the resident fell from the bath chair and sustained a left femoral neck (hip) fracture, certified nurse aides (CNAs) moved the resident from the floor back to the bath chair using a mechanical lift without waiting for a nurse to assess the resident. The CNAs reported waiting for help for 10-15 minutes before transferring the resident themselves, and only after the transfer did a nurse arrive to perform a skin check and basic assessment. The resident involved had a history of dementia, impaired balance, limited mobility, and weakness, and required assistance of two with a gait belt for transfers. The care plan did not include the use of a sit-to-stand lift, which was used by staff following the incident. The nurse did not perform a full-body assessment prior to the transfer, as required by policy, and the transfer method used was not part of the resident's care plan or assessed for safety. These actions and inactions resulted in a failure to follow established protocols for post-fall assessment and safe transfer, potentially contributing to further injury and pain for the resident.