Resident Fall During Unsupervised Transfer to Commode
Penalty
Summary
A deficiency occurred when a resident with a non–weight-bearing order for the left lower extremity and a history of a distal left femur fracture was not provided adequate supervision during a transfer. The resident, who also had stage 4 chronic kidney disease and was on Eliquis, used a walker and was to bear weight only on the right leg during transfers, with a gait belt in use. While the resident was being assisted from bed to a bedside commode, the CNA providing assistance left in the middle of the transfer to respond to other call lights, before the resident was fully seated. During this unsupervised moment, the resident attempted to complete the transfer independently, became tangled while positioning the walker, and fell forward to the floor, landing on her face. The resident reported that she had gotten up to use the bedside commode and was trying to sit further back when she became tangled and fell. The fall resulted in a superficial abrasion over the nose and a minimally impacted anterior nasal bone fracture, with CT imaging showing mild soft tissue swelling over the anterior nasal bridge and no acute intracranial findings. At the time of the incident, the resident also had oxygen tubing in place and the nurse assigned to the resident was charting across the room.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.