Failure to Follow Transfer Requirements and Fall-Prevention Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfers and appropriate fall prevention measures for two residents. One resident with dementia and Alzheimer’s disease, who was dependent on staff for most ADLs, was care planned and documented in the Kardex as requiring a one-person stand-and-pivot transfer with a gait belt. There was no documentation in the EMR indicating a need for a Sara lift or any other mechanical transfer device. Despite this, a CNA used a Sara lift to transfer the resident from bed to wheelchair, during which the resident experienced a witnessed fall, sustaining a head injury and a skin tear to the left wrist and requiring transfer to the ER. The DON confirmed that the fall occurred because the CNA used a Sara lift even though the resident did not require one, and both the CNA and DON stated that staff are expected to be familiar with each resident’s transfer requirements. The second resident, with aphasia, dementia, and Alzheimer’s disease, had a documented history of nine falls, including falls from bed and wheelchair related to leaning forward, confusion, balance problems, poor communication/comprehension, and unawareness of safety needs. The resident’s care plan included interventions such as placing a fall mat on both sides of the bed when the resident was in bed. However, review of the EHR showed that required fall risk assessments had not been completed since September 2024, despite the facility’s expectation that such assessments be done on admission, quarterly, and after each fall. During an observation, the resident was found lying in bed without the fall mat in place as care planned; instead, the mat was stored against the wall. The DON confirmed that the fall risk assessments were not completed as required and that the fall mat should have been present whenever the resident was in bed.
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