Failure to Follow Care Plans for Safe Transfers and Fall Prevention
Penalty
Summary
The facility failed to ensure safe transfers and implement fall prevention interventions as outlined in the care plans for two residents. One resident, identified as high risk for falls, had a care plan requiring two staff members for all transfers. Despite this, a Certified Nursing Assistant reported transferring the resident alone, having the resident wrap their arms around her neck and performing the transfer without assistance. This was confirmed through staff interview and review of the resident's care plan and progress notes, which documented a recent fall and the resident's unsteady condition during transfers. Another resident, also assessed as high risk for falls with a documented history of multiple falls, had a care plan intervention requiring a "call don't fall" sign to be placed in their room. Observation revealed that the sign was not present, and this was confirmed by a Licensed Practical Nurse. The absence of the required signage and failure to follow the care plan intervention were directly observed and verified through staff interview and record review.