Failure to Reevaluate Transfer Needs and Report Fall Incident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, diabetes, and a right leg amputation was not properly reevaluated for transfer assistance after being unable to use a prosthetic leg due to a blister and improper fit. Despite a physician order discontinuing the use of the prosthesis and a subsequent order for mechanical lift transfers, there was no documentation that the resident’s transfer status was reassessed when the prosthesis was removed. Staff continued to use manual transfer methods without a gait belt or walker, contrary to the care plan and physician orders, and did not consult therapy for updated transfer recommendations. The resident experienced a fall during a transfer attempt by two CNAs who did not use a mechanical lift or gait belt, and involved the resident’s roommate in the process. The fall was not immediately reported to nursing staff as required. Instead, the CNAs attempted to conceal the incident, instructing each other and the resident not to report it. The fall only came to light two days later when another CNA reported it to a nurse, prompting a delayed assessment and notification of the nurse practitioner. There was no immediate post-fall assessment or thorough investigation at the time of the incident. Interviews and record reviews revealed that staff were unclear about the resident’s current transfer needs and failed to follow established protocols for safe transfers and fall reporting. The facility’s policies required prompt reassessment after a change in condition, use of appropriate transfer equipment, and immediate reporting and investigation of falls. These procedures were not followed, affecting the resident involved and potentially impacting other residents on the same units.