F0689

G

Failure to Follow Transfer Orders and Implement Fall/Incontinence Interventions Resulting in Resident Injuries

Canton, Connecticut Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents. For one resident with hemiplegia and hemiparesis affecting the left, non-dominant side, the physician’s admission assessment documented that the resident was chair bound with no ability to move the left upper or lower extremity, and physician orders, the care plan, and the nurse aide care card all directed an assist of two staff for bed mobility and transfers. Despite these orders, a nurse aide moved the resident in bed alone. The aide reported that he was in a rush, stood at the head of the bed, grasped the transfer sheet with one hand and the resident’s left shoulder with the other, and pulled the resident up in bed, even though he was aware that two-person assistance was required for bed mobility.

Following this event, the resident complained of shoulder pain and reported hearing a pop while being moved in bed by the aide. Nursing documentation identified complaints of left shoulder, arm, and hand pain, with intact sensation but no active movement in the left upper extremity at baseline, and noted greenish-yellow ecchymosis on the left hand. An x-ray of the left shoulder showed a normal left humerus with an anterior dislocation of the left shoulder. The facility was unable to provide a transfer policy when requested, and the director of nursing confirmed that the aide had moved the resident in bed without assistance, contrary to the provider’s orders for two-person assistance with bed mobility.

The deficiency also involves a second resident with dementia, cerebral infarction, difficulty in walking, severely impaired cognition, impaired balance, and progressive urinary and bowel incontinence who was at high risk for falls. The resident’s care plans over time identified fall risk and directed interventions such as applying gripper socks while in bed, instructing the resident to ask for assistance before ambulating, placing the call bell within reach, and orienting to surroundings. However, the care plans repeatedly lacked clear goals and adequate interventions for incontinence care and did not include a toileting plan or schedule, despite MDS assessments documenting occasional and later frequent incontinence and the resident’s severe cognitive impairment. The bowel and bladder assessment was not completed on readmission after a hospitalization, contrary to facility policy.

This resident experienced multiple unwitnessed falls, several associated with toileting needs. Incident reports documented falls in the bathroom and in the room, including one with the wheelchair tipped over and another due to ambulating without assistance. Later documentation showed the resident was frequently incontinent of bowel and bladder, yet the care plan still did not include a toileting schedule. The resident sustained an unwitnessed fall under the bathroom sink with skin tears and rib pain, and after readmission with rib fractures, the care card continued to list the resident as continent and did not provide a toileting plan, instead listing only transfer status. In a subsequent fall from bed while attempting to use a urinal, the resident was not wearing gripper socks, and the assigned nurse aides reported they were unaware that gripper socks were required in bed and did not identify this need from the care card. The director of nursing services acknowledged that the resident should have had a toileting plan/schedule based on severe cognitive impairment and incontinence patterns and that a bowel and bladder assessment should have been performed on readmission, but these were not implemented, and gripper sock interventions were not consistently carried out at the time of the fall.