Failure to Implement Therapy Recommendations for Safe Transfers
Penalty
Summary
A deficiency was identified when a resident with multiple complex diagnoses, including sarcoid myocarditis, muscle weakness, and difficulty walking, experienced a fall during a transfer from a recliner to a wheelchair. The fall occurred when the resident's knees buckled, and the CNA assisted the resident to the floor and then to a wheelchair with a two-person stand and pivot. The root cause investigation determined that the fall was due to the resident's leg weakness, and the resident's fall risk assessment was updated from low to moderate following the incident. Despite recommendations from the physical therapist for staff to use a front-wheeled walker and a gait belt during transfers, interviews with CNAs revealed that these assistive devices were not being used. The resident confirmed that staff did not use a gait belt or walker when transferring, even though the physical therapist had recommended their use. The care plan and Kardex were updated to indicate a two-person assist for transfers after the fall, but did not specify the use of a gait belt or walker as recommended by therapy. The Director of Nursing confirmed that using a gait belt is considered standard of care and that staff are educated on therapy recommendations through a communication binder and updates to the Kardex system. However, the DON was not aware of the specific PT recommendation for the use of a walker during transfers for this resident. The facility's falls protocol requires staff to identify and implement pertinent interventions based on assessment, but the lack of adherence to therapy recommendations for assistive devices contributed to the deficiency.