Failure to Safely Transfer Resident Resulting in Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with a history of dementia, stroke, right lower leg wound, and transient ischemic attack without following the resident's care plan, which required two staff members for all transfers and toileting. The CNA transferred the resident alone and did not use a gait belt, instructing the resident to hold onto the bathroom grab bar. During the transfer, the resident's legs gave out, resulting in a fall to the bathroom floor. The CNA was unable to prevent the fall due to the absence of a gait belt and lack of assistance. Multiple staff members responded to the incident, finding the resident on the bathroom floor, kneeling and in pain, with her legs trapped between the toilet seat and grab bar. It required three staff members to safely assist the resident back to her wheelchair. The resident sustained a small skin tear to her left arm as a result of the fall. The facility's policy on safe lifting and movement of residents requires the use of appropriate techniques and devices to ensure safety, which was not followed in this incident.