Failure to Provide Adequate Supervision During Dependent Transfer Resulting in Fall With Injury
Penalty
Summary
Facility staff failed to provide adequate supervision and safe transfer assistance for Resident #98, resulting in a fall with injury during a wheelchair-to-bed transfer. Resident #98 had diagnoses including Alzheimer's disease, essential hypertension, major depressive disorder, and muscle weakness, and was assessed on the MDS as severely cognitively impaired with a BIMS score of 0/15. The MDS Section GG dated 8/15/23 coded the resident as dependent for chair/bed-to-chair transfers, meaning the helper did all of the effort or that assistance of two or more helpers was required. An occupational therapy treatment note dated 8/25/23 documented that the resident required total assist for stand-pivot transfers to a wheelchair. Despite these documented needs, a single CNA attempted to transfer the resident from a wheelchair to the bed. During the transfer, the CNA and the resident lost their balance and both fell to the floor. Post-fall documentation and the CNA’s statement indicated that the resident became combative, resisted care, pushed against the CNA, and the CNA then tripped over the leg rest, leading to the resident falling face forward to the ground. Nursing notes documented that the resident was found on her left side on the floor with blood present and a laceration to the middle of the forehead, was assisted back to bed with a two-person assist, and was sent to the emergency department. Hospital records and subsequent nursing documentation confirmed diagnoses of a facial laceration, a closed fracture of the nasal bone, and a closed nondisplaced fracture of the second cervical vertebra. The DON and Director of Rehabilitation both stated that, given the resident’s dependent/total assist status for transfers, the CNA should have maintained hands-on assistance at all times and/or had assistance from another staff member during the transfer.
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