Failure to Provide Safe Transfer Assistance Resulting in Resident Falls and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate assistance during transfers, resulting in accidents for two residents. One resident with intact cognition, Parkinson’s disease, contractures, stiffness of both knees, reduced mobility, bipolar disorder, depression, and anxiety was care planned as dependent for all ADLs and required a full-body mechanical lift with a sling sized to weight. During a transfer with a full-body mechanical lift, CNAs attached all four sling loops to the lift hooks while the resident was in bed and then raised the resident above the bed. As the lift was rotated toward the chair, one of the sling loops came off a hook, causing the resident to slide feet first out of the sling to the floor. Staff physically supported the resident’s upper body to prevent head impact, but the resident later reported rib pain, and imaging confirmed an acute fracture of the right 10th rib. Staff interviews revealed that one CNA operated the lift controls while the other guided the resident in the sling. They described that the bottom strap on one side came off during the transfer, leading to the resident’s legs and then upper torso coming out of the sling. One CNA stated she believed the strap may not have been fully secured on the hook and that only two staff were present in the room during the transfer. Another CNA reported uncertainty about which straps she had hooked and suggested that the direction of pivoting might have displaced pressure and contributed to the strap coming off. Staff also noted that the facility had three full-body mechanical lifts, two of which did not have safety hooks, and that the lift used in this incident was one of the lifts without safety hooks. The deficiency also includes an incident involving another resident with intact cognition and diagnoses including chronic kidney disease, coronary artery disease, atrial fibrillation, congestive heart failure, anxiety, and use of antidepressant, opioid, and diuretic medications, who was care planned as being at risk for falls. A CNA (agency staff) assisted this resident to transfer from bed to wheelchair. The CNA reported that no one had informed her of the resident’s required level of assistance, so she asked the resident, who stated she could get herself up. The resident stood while the CNA held onto her pants, took one step, and then fell backward onto the bed, landing on both arms and reporting severe right shoulder pain. The progress notes documented the fall backward into the bed during the transfer, the resident’s report of right shoulder pain rated 10/10, and slightly limited range of motion in the right upper arm. The DON later stated that a gait belt should have been used when assisting this resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.