Failure to Use Safe Transfer Techniques and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to ensure safe transfer techniques and adequate supervision to prevent accidents for multiple residents, resulting in significant injuries and incomplete post-fall assessments. One resident with severe cognitive impairment and a history of fractures was transferred using a mechanical lift by a CNA who did not follow manufacturer instructions for sling attachment. The resident fell from the lift, sustaining a sacral fracture, tibial plateau fracture, and head injury. The CNA operated the lift alone, did not cross the sling straps as required, and the incident was not immediately reported to the state agency. The facility's own policy and the lift manufacturer's instructions were not followed during this transfer. Another resident with severe cognitive impairment and a history of falls was assisted from a dining room chair without the use of a gait belt, contrary to care plan requirements. The resident fell, complained of dizziness and back pain, and developed a chin bruise. Staff failed to check the resident's range of motion before moving her from the floor, and neurological assessments were not completed as required by facility protocol. Similarly, a third resident with severe cognitive impairment and a history of crawling on the floor was found on the floor by staff, but the event was not treated as an unwitnessed fall, and a neurological assessment was not initiated as required by policy. Additionally, another resident dependent on two staff for transfers was observed being transferred by a single CNA without a gait belt, in violation of the care plan and facility policy. Staff interviews confirmed that transfers were not performed according to established protocols, and staff were not consistently using required safety equipment. Facility policies on safe lifting, neurological assessment, and fall protocols were not followed, leading to preventable injuries and incomplete post-incident assessments for multiple residents.