Failure to Implement Fall Prevention Measures During Transfer
Penalty
Summary
A deficiency occurred when the facility failed to implement fall prevention measures for a resident who required a two-person assist for transfers due to limited mobility following hip surgery. The resident had a complex medical history, including a periprosthetic fracture around an internal prosthetic right hip joint, a history of falls, essential hypertension, myelodysplastic syndrome, anemia, orthostatic hypotension, osteoporosis, and the presence of a right artificial hip joint. Despite being assessed as needing a two-person assist for all transfers and having this requirement documented in the care plan and transfer status binder, the resident was transferred from the toilet to a wheelchair by only one certified nurse aide (CNA). During the transfer, the resident experienced sudden weakness in the right leg and was lowered to the floor by the CNA. Initial assessment revealed no pain, but upon reassessment, the resident reported right hip pain. An x-ray confirmed a dislocation of the right hip prosthesis, and the resident was subsequently sent to the emergency room for further evaluation and treatment. Interviews with facility staff, including the DON, RN, and Restorative Nurse, confirmed that the resident was supposed to have two-person assistance for transfers due to surgical status and fall risk, and that this protocol was not followed at the time of the incident. Documentation in the resident's care plan, functional assessments, and restorative progress notes all indicated the need for two-person assist with transfers, specifically using a walker and transferring toward the resident's stronger side. Facility policies on transfer and fall management emphasized individualized assessment, adherence to physician and therapy recommendations, and proper documentation and communication of transfer needs. The failure to follow these established protocols and care plan interventions directly led to the resident's fall and subsequent injury.