F0689

D

Failure to Safely Supervise Transfer and Investigate Alleged Fall

Sacramento, California Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate and sufficient supervision during a transfer and to ensure the environment was free from accident hazards for a cognitively intact resident with significant prior pelvic fractures and hip pain. The resident had a history of a serious pelvic ring and pubic ramus fracture following a fall and required substantial/maximal assistance for bed-to-chair transfers per the MDS. On the morning in question, CNA 1 informed a CNA instructor that the resident preferred a bed bath due to hip pain and instructed the instructor to call him for assistance before attempting the first out-of-bed transfer. Despite this, the CNA instructor and CNA students proceeded to transfer the resident from bed to a shower chair without calling CNA 1 for help.

According to CNA 1, he left his gait belt in the room for the instructor to use and then left to care for another resident. He later heard a commotion and, upon returning, heard the resident repeatedly saying she had been dropped. CNA 1 observed redness on the resident’s lower legs and heard complaints of leg and back pain, and he saw the gait belt lying on a table across the room, leading him to suspect it had not been used during the transfer. The resident reported that three female students and their instructor attempted to transfer her, that she warned them she was going to fall, and that the instructor reassured her they had her before her legs buckled and she fell onto her knees on the floor. The resident stated the group could not lift her, and a male student entered and picked her up from the floor to the shower chair before CNA 1 arrived.

An anonymous witness reported being present in the room and stated that four CNA students and the instructor were assisting with the resident’s shower and that, when the resident complained of pain, the instructor told the group to hurry with the transfer. The witness stated the resident slipped toward the ground, yelled that she was being dropped, and ended up on the floor on her legs, with one leg bent backward on her knee. The witness further stated there were no staff present and that no nurse was notified before the resident was picked up from the floor by the male student. Documentation on the shower sheet noted slight redness and discoloration at the resident’s lower legs, signed by CNA 1 and an LVN. Facility leadership, including the DSD and DON, acknowledged conflicting accounts about whether the resident fell, confirmed that the resident and at least one CNA student reported a fall, and stated that no fall assessment, IDT meeting, or documented investigation was completed, despite facility policy requiring investigation and reporting of all accidents and incidents.

A physician progress note documented that the resident expressed anxiety about being in the facility because she reported being dropped during a transfer that morning and stated she was scared of falling again. During a record request, the facility was unable to provide any documentation that an investigation of the alleged fall had been conducted, even though the facility’s written policy on accidents and incidents required prompt investigation and reporting of all such events by the nurse supervisor/charge nurse or department director, including specific data elements on an incident/accident report form.