F0689

J

Failure to Use Ordered Transfer Aids Resulting in Resident Fall and Hip Fracture

Van Alstyne, Texas Survey Completed on 01-31-2026

Penalty

Fine: $21,645

Summary

The deficiency involves the facility’s failure to ensure an area was free from accident hazards and that adequate supervision and assistive devices were provided to prevent accidents, specifically for one resident. The resident was a 78-year-old female with diagnoses including muscle weakness, unsteadiness of feet, lack of coordination, convulsions, osteoporosis, and a history of falls. Her MDS showed moderate cognitive impairment and a need for partial/moderate assistance with sit-to-stand and chair/bed-to-chair transfers. She was identified as high risk for falls, and the NP had ordered strict fall precautions due to impaired balance. Despite these risk factors, her comprehensive care plans only generally stated that she would receive assistance with transfers and ambulation and would use adaptive equipment such as transfer aids, but they did not specify the exact mode of transfer or required transfer device. There was no physician order detailing how she should be transferred.

On the day of the incident, CNA A attempted to transfer the resident from bed to wheelchair without using any transfer aid such as a gait belt or sit-to-stand lift. Multiple staff interviews confirmed that the resident’s mode of transfer had been changed from stand-and-pivot to use of a sit-to-stand mechanical lift due to weakness, and that staff, including CNA A, were aware of this recommendation and had previously used the sit-to-stand with the resident. CNA A acknowledged knowing the resident was a sit-to-stand transfer and admitted she did not use the sit-to-stand on the day of the fall. RN B and the Weekend Supervisor both stated that if the resident was a one-person assist, a gait belt should have been used, and that transfer aids such as gait belts and mechanical lifts were expected for safety. RN B reported seeing the gait belt hanging on the wall unused when she entered the room after the incident.

During the transfer, the resident lost her balance; staff reported that one of her knees gave out and she ended up kneeling on the floor beside the bed, with her upper body leaning on the bed. The resident complained of severe left hip pain rated 10/10 and requested to be sent to the hospital. She later reported that CNA A did not use a gait belt or a machine, while other CNAs did use a machine when transferring her. The DON and other staff confirmed that prior to the incident the resident was considered a one-person assist and that staff were supposed to use a gait belt and, if ordered, the sit-to-stand lift. The DON also acknowledged that therapy had recommended changing the resident’s mode of transfer to sit-to-stand and that she failed to follow up on whether this recommendation was finalized and implemented. There was no documentation that the resident refused the sit-to-stand prior to the fall. The combination of an unclear, nonspecific care plan, lack of a specific transfer order, failure to follow therapy’s transfer recommendations, and CNA A’s failure to use the required transfer aid during the transfer led to the fall and subsequent left hip fracture.

The surveyors determined that this failure to provide adequate supervision and assistance devices to prevent accidents constituted noncompliance with F689 and resulted in an Immediate Jeopardy situation. The incident showed that the resident, who had multiple fall and fracture risk factors and was on strict fall precautions, was transferred without the prescribed or expected transfer aids, and that the facility had not ensured that the care plan and medical record clearly and specifically directed staff on the resident’s required mode of transfer. Interviews with multiple staff members revealed inconsistent understanding and implementation of the resident’s transfer status and highlighted that, at the time of the incident, the resident’s transfer needs were not consistently communicated or followed, directly contributing to the accident.

Removal Plan

• Resident #1 evaluated by nursing staff
• Resident #1 care plan updated to reflect current transfer status (requires sit-to-stand lift)
• Order placed in the electronic medical record for mechanical lift transfers for Resident #1
• Physical Therapy referral placed in the electronic medical record for evaluation and treatment for Resident #1
• All licensed nurses, CNAs, and therapy staff educated on Safe Resident Handling/Transfers policy prior to working their next shift (including telephone education for absent staff)
• All new hires and agency staff to receive Safe Resident Handling/Transfers policy education before providing resident care
• 1:1 education provided to the Director of Nursing on following therapy recommendations for resident transfers and discussing transfer needs in clinical meetings and Standards of Care meetings
• DON/designee reassessed all residents using the Fall Risk Assessment Tool
• MDS/MOS nurse ensured all residents identified as at risk for falls had safety measures and resident-specific interventions added to their care plans
• MDS/MOS nurse ensured added safety measures/interventions were reflected in both electronic and paper medical records so CNAs had access
• DON/designee instructed CNAs to review the updated paper medical record prior to their next shift
• Audit of all residents requiring assistance with transfers to ensure accuracy of transfer status and updated care plans
• Audit of all therapy recommendations to ensure they were reviewed and followed
• Safe Resident Handling/Transfers policy reviewed
• DON/designee to audit new admissions daily to ensure Fall Risk Assessment completion and that risk factors, safety measures, and resident-specific interventions are reflected on the care plan and updated on the Kardex
• Regional Nurse Consultant to review all falls within 72 hours to ensure an RCA is conducted and resident-specific interventions are reflected in the care plan and updated in paper/electronic care plans
• DON/designee to review all falls at the daily stand-up meeting with the IDT to ensure appropriate fall interventions are implemented, the care plan is reviewed/revised, and the Kardex is updated
• Interdisciplinary team to review all audit results in QAPI with additional training provided if trends are identified
• Medical Director notified of the deficient practice/Immediate Jeopardy and the Plan of Removal