Failure to Prevent Accidents During Assisted Transfers and Care
Penalty
Summary
The facility failed to ensure resident safety and prevent accidents for two residents who required staff assistance during care. One resident, with a history of congestive heart failure, a left knee prosthetic joint, and chronic kidney disease, was identified as a fall risk and required a knee immobilizer during transfers and ambulation. Despite medical orders and care plan interventions specifying the use of a knee immobilizer, the resident was transferred by a CNA who was unaware of this requirement and did not observe the immobilizer in the room. During an assisted transfer from the commode to the bed, the resident was not wearing the immobilizer, resulting in a fall and a mid femur fracture. The CNA reported not knowing about the immobilizer, and the LPN confirmed that communication regarding the immobilizer was lacking. Another resident, admitted with diagnoses including atrial fibrillation, osteoporosis, and a history of hip fracture, required one-person physical assistance with all activities of daily living, including bed mobility. During incontinence care, the resident rolled out of bed while being turned by a CNA and sustained a left hip fracture. The CNA stated that the resident's leg was sliding off the bed, and while attempting to move to the other side to assist, the resident fell to the floor. The CNA acknowledged that calling for assistance could have been an option but did not do so, stating the incident happened quickly. Interviews with staff, including the DON, revealed a lack of effective communication and root cause analysis regarding these incidents. The facility's policy on fall risk assessment and prevention was in place, but the events demonstrated failures in its implementation, particularly in ensuring staff awareness of resident-specific safety interventions and the need for adequate supervision during care.