Failure to Prevent and Document Resident Fall During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with moderate cognitive impairment, diabetes, congestive heart failure, and morbid obesity. The resident, who was dependent for transfers and self-care and incontinent, was identified as being at risk for falls. During a mechanical lift transfer from wheelchair to bed, the resident slipped through the sling and fell to the floor due to a wet brief, despite the sling being placed appropriately. Multiple staff interviews confirmed the fall, and the resident's representative was notified by phone. However, there was no incident report available for the representative, and the resident was later discharged to another facility. Further review revealed significant lapses in documentation and follow-up. The nurse on duty after the fall was unaware of the incident until contacted by the resident's representative, and her subsequent documentation was deleted. The DON confirmed that required documentation, including risk management and progress notes, could not be found in the medical record, and there was no follow-up with risk management. The nurse practitioner was not notified of the fall, and the resident's care plan was not updated post-incident. Facility policy required assessment, post-fall assessment, incident reporting, physician and family notification, care plan review, documentation, and witness statements, none of which were fully completed in this case.