Failure to Provide Required Two-Person Mechanical Lift Assistance Resulting in Resident Fall
Penalty
Summary
The facility failed to ensure a resident’s safety during care by not providing adequate supervision and assistance during a transfer, resulting in a fall. On 11/21/25, an LPN (V3) reported that while passing morning medications, a CNA (V4) asked her to come to the resident’s (R1’s) room, where R1 was upset and angry as V4 was about to get him up for breakfast. When V3 entered the room, R1 was holding onto the side rails, turned over to his left side, and then fell over the side rails. The LPN stated she did not know why the CNA was alone attempting to get R1 up. R1’s fall incident report documented that R1 turned over too quickly and flipped himself over the side rails, and listed predisposing physiological factors including resistance to care, weakness, agitation, anxiety, involuntary movements, and decreased strength. R1’s care plan, which identified him as at risk for falls related to multiple sclerosis with contractures, tremors, impaired cognition, impulsivity, psychiatric diagnosis with behaviors, and self-care deficits, specified that he was dependent in ADLs, required total assistance with hygiene and dressing, needed two staff for turning and repositioning, and required transfers with a mechanical lift with two staff. The DON (V2) confirmed that R1 was at high risk for falls due to MS and required two staff assistance for all care for safety. The deficiency centers on the facility’s failure to follow the resident’s care plan and provide the required two-person assistance and mechanical lift during transfer activities, as evidenced by the CNA being alone with the resident at the time of the incident and the subsequent fall over the side rails.
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