F0689

G

Failure to Follow Transfer Policy and Provide Adequate Supervision for High-Risk Residents

Springfield, Illinois Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own transfer and fall-prevention policies and to provide adequate supervision, resulting in improper handling of one resident found on the floor and a fall with fracture for another resident. One resident (R2), with diagnoses including sepsis, cerebral infarction, type 2 diabetes, dementia, and cellulitis of the buttock, was severely cognitively impaired, dependent for mobility and transfers, and had documented upper and lower one-sided impairment. R2’s care plan identified a high risk for falls related to stroke history, traumatic brain injury, dementia, prior falls, incontinence, and medication use, with interventions such as a low bed, fall mat, bed/chair alarm, non-skid footwear, and keeping the resident within staff vision when up. R2’s fall assessment documented a high fall risk.

Video evidence reviewed by the surveyor showed that on the evening of the incident, a CNA (V5) entered R2’s room where R2’s arm reached toward the CNA, and V5 then picked R2 up from the floor by the shoulders and forcefully placed the resident on the bed. The CNA then pulled on R2’s right leg and shirt to straighten the resident in bed and raised the bed, placing a pillow behind R2. During this transfer, R2 could be heard calling out “Ouch” and moaning. No gait belt, mechanical lift, staff assistance, or nursing assessment was used during this transfer, despite the facility’s transfer policy requiring that a nurse first assess any resident who has fallen and that, if medically appropriate, a full-size mechanical lift be used to transfer a resident from the floor. R2’s progress note later documented that it was reported the resident had rolled out of bed onto the floor and was observed lying on the fall mat, with an assessment noting range of motion and neurological status within normal limits and no visible injuries.

The facility’s abuse and fall investigations for R2 documented that the nurse on duty (V4, LPN) was not informed by the CNA that R2 had been on the floor, and other CNAs (V6 and V7) reported they were not aware of a fall and had not been asked to assist with a transfer. The Administrator (V1) stated that the incident was not reported by V5, that V5 did not tell the nurse that R2 had fallen or was on the floor, and that the transfer was not done in accordance with policy. R2’s family member reported having a video recorder in the room, observing V5 “very forcefully” handling R2 from the floor to the bed, hearing R2 yell “Ouch,” and submitting the video as a complaint.

A second resident (R6) experienced a fall resulting in fractures. R6 had diagnoses including senile degeneration of the brain, hypertensive heart disease with heart failure, CHF, atrial fibrillation, and metabolic encephalopathy, and had a BIMS score of 4, indicating significant cognitive impairment. R6 required partial/moderate assistance with mobility, transfers, and walking, and was care planned as high risk for falls with interventions such as a cushion, nonskid footwear, and a clear pathway. R6’s progress notes documented that a CNA alerted the nurse that R6 was found on the floor in another resident’s bathroom, in the shower area, with the resident’s head and back against the shower wall, legs positioned toward the door, and the resident holding the left shoulder while tearful and complaining of pain in the head, left shoulder, buttocks, and right lower extremity, and verbalizing inability to move.

The initial fall investigation for R6 documented that approximately 20 minutes before being found on the bathroom floor, R6 had been assisted to the bathroom and then to bed, with the call light placed within reach. After the fall, R6 complained of pain to the left shoulder, right lower extremity, and buttocks, and would not allow staff to assist off the floor due to pain. Vital signs and neurological checks were within normal limits, and the resident was sent to the emergency room at the request of the power of attorney. A CT scan showed a nondisplaced avulsion fracture of the right ilium and a minimally displaced right distal clavicle fracture. Staff interviews described R6 as very confused and a wanderer who frequently got up on her own despite use of a bucket seat and cushion, and that multiple staff, including kitchen staff, would remind her to sit down. Despite R6’s known wandering behavior and high fall risk, she was able to leave her bed area and be found on the floor in another resident’s bathroom, indicating that supervision and fall-prevention measures were not sufficient to prevent this fall and resulting injury.

The facility’s written transfer policy required that when a resident falls to the floor, a nurse must first assess the resident and, if medically appropriate, a full-size mechanical lift must be used to transfer the resident from the floor, or EMS must be called if not medically appropriate. The fall policy required assessment of each resident’s fall risk on admission, quarterly, and with each fall, to guide care planning and monitoring to reduce injury risk. In R2’s case, the CNA did not follow the transfer policy, moved the resident from the floor without a nursing assessment or mechanical lift, and did not report the fall to nursing staff. In R6’s case, despite documented high fall risk and known wandering, the resident was able to ambulate unsupervised to another resident’s bathroom where the fall occurred, resulting in fractures, demonstrating that the facility did not provide adequate supervision or effective implementation of fall-prevention interventions for this resident.