Failure to Follow Care Plan During Transfer Results in Resident Fall and Head Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan during a transfer, resulting in a fall and significant injury. The resident, who had diagnoses including hypertension, atrial fibrillation, generalized weakness, and mobility impairments, required substantial or maximal assistance for transfers and mobility, as well as the use of a gait belt and appropriate footwear. On the day of the incident, a nursing assistant transferred the resident from bed to the bathroom for a weight check without providing footwear or using a gait belt, and left the resident standing unsupported on the scale. While stepping off the scale, the resident lost balance and fell, hitting her head against the wall. The fall was witnessed, and it was documented that the staff did not assist the resident during the transfer as required by the care plan. The resident was on blood thinners, which increased the risk of complications from head injuries. Following the fall, the resident exhibited increased confusion and drowsiness, and was later found to have a brain bleed confirmed by CT and MRI scans. Interviews with staff and family confirmed that the care plan was not followed during the transfer, and that the resident was left unsupported and without necessary safety measures. The incident was reported to the provider and family, and neuro checks were initiated. The failure to adhere to the care plan and established safety protocols directly led to the resident's fall and subsequent injury.