Failure to Follow Transfer Protocols and Post-Fall Assessment Leads to Resident Injury
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to demonstrate competency in the care of a resident by not following the resident's care plan and by moving the resident prior to a nurse assessment following a fall. Specifically, one CNA attempted to transfer a resident from bed to wheelchair without using the required mechanical stand-up lift and without a second staff member to assist, as mandated by the resident's care plan. During this improper transfer, the resident's legs gave out, resulting in the resident falling to their knees on the floor. After the fall, the CNA requested assistance from another CNA, and together they moved the resident from the floor to a wheelchair before the resident was assessed by a nurse, despite the resident complaining of pain. Both CNAs admitted in interviews that moving the resident prior to a nurse's assessment was not appropriate. The resident was later found to have sustained an acute right femoral fracture, which required surgical intervention. The resident involved had a history of scoliosis, unsteadiness on feet, dementia, and was care planned for transfers with a mechanical stand-up lift and two-person assist due to dependency in activities of daily living and a recent history of falls and fractures. Staff interviews and record reviews confirmed that the care plan was not followed, and the required protocols for post-fall assessment were not adhered to, resulting in significant harm to the resident.
Removal Plan
- All licensed nursing staff and certified nursing assistants will be in-serviced by the Director of Nursing (DON)/designee on the proper steps taken after a resident has sustained a fall, to prevent serious harm, serious injury, serious impairment, or death.
- All Certified Nursing Assistants (CNAs) and licensed nurses will be educated and in-serviced by the DON/designee on proper resident transfers to prevent serious harm, serious injury, serious impairment or death.
- All CNAs and licensed nurses will be educated and in-serviced by the DON/designee on locating and reviewing the care plan prior to resident care and implementing the care plan during resident care to prevent serious harm, serious injury, serious impairment, or death.
- All licensed nurses and CNAs will be educated to check the Kardex /plan of care, located in the kiosk, on a resident and implement it, also the proper steps to take after a resident sustain a fall, and to be educated on the proper transfer technique to prevent serious harm, serious injury, or death.
- The DON/designee will visually monitor residents being transferred, visually monitor licensed nurses and certified nurse assistants on locating, reviewing the plan of care, and implementing the plan of care, also proper steps taken when a resident sustains a fall, by CNA, and licensed staff, to prevent serious harm, serious injury, or death 5 times a week for 8 weeks or until compliance is verified by Office of Long-Term Care.
- The DON/designee will present all findings to the monthly QAPI (Quality Assurance & Performance Improvement) committee for further review and recommendations.