Failure to Provide Adequate Supervision and Follow Transfer Protocols Resulting in Resident Falls
Penalty
Summary
The facility failed to provide adequate care and services to prevent falls for two residents who were identified as being at risk. One resident, with diagnoses including pulmonary hypertension, dementia, and spondylosis, was assessed as needing two-person assistance for bed mobility and touch assistance for transfers. Despite this, the resident was transferred using a mechanical lift by only one CNA, contrary to both the resident's care plan and facility policy, which required two trained staff for such transfers. During the transfer, the mechanical lift strap broke, causing the resident to fall backwards onto the bed, though no injuries were noted. Another resident, with a history of heart failure, hypertension, multiple cancers, muscle weakness, and impaired cognition, was care planned for two-person physical assistance with transfers and did not ambulate at baseline. This resident experienced a fall while being re-weighed at the weight station. The resident was being assisted by only one LPN, who was using a gait belt, when the resident lost balance and was eased to the floor. The care plan specified two-person assistance for transfers, but only one staff member was present at the time of the incident. In both cases, staff actions did not align with the residents' care plans or facility policies regarding the required number of staff for transfers and use of mechanical lifts. These failures resulted in falls, though neither resident sustained major injuries. The facility's policies and care plans were not followed, leading to deficiencies in accident prevention and supervision.