Improper Manual Transfer Leads to Fall During Shower
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention and transfer policies during a staff-assisted transfer, resulting in a witnessed fall for one resident. The facility’s Fall Prevention Program Policy requires assessment of fall risk, implementation of appropriate safety interventions, use of mechanical lifting devices for residents needing a two-person assist, and communication of these needs to direct care staff. The Transfers-Manual Gait Belt and Mechanical Lift Policy further specifies that mechanical lifting devices must be used for any resident needing a two-person assist or who cannot be transferred safely, and that direct care staff will be trained in their use. Despite these policies, a Certified Nursing Assistant (CNA) attempted to transfer the resident alone in the shower room without using a mechanical lift, contrary to the resident’s care plan and facility policy. The resident involved had multiple significant diagnoses, including cerebrovascular disease, major depressive disorder, senile degeneration of the brain, dementia, adult failure to thrive, and was under hospice care. The resident’s current care plan documented total dependence on two staff members for bed mobility, dressing, grooming, bathing, positioning, and transfers using a mechanical lift with two staff. On the date of the incident, the CNA reported that while in the shower room, her foot slipped during the transfer, the resident’s feet slid, and she grasped the resident’s upper arms and lowered the resident to a seated position on the floor. A witnessed fall report and nursing notes documented that the resident was lowered to the floor during this transfer, later complained of right shoulder pain, and an X-ray was obtained, which was negative for fracture. The administrator confirmed that the resident was supposed to be transferred with a mechanical lift and two-person assistance and that the CNA had improperly transferred the resident alone.
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