Failure to Follow Fall Protocol and Transfer Requirements After Assisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow fall protocol and the resident’s care plan by not notifying a nurse immediately after an assisted fall and by moving the resident before a licensed nurse assessment. The resident involved had dementia, ESRD on hemodialysis, diabetes, portal vein thrombosis treated with Eliquis, and an aneurysm of the upper extremity artery. Her MDS and care plan specified that she was totally dependent for transfers and required a one-person mechanical lift with a medium sling for all transfers. On the day of the incident, the resident returned from dialysis, ate lunch, and repeatedly requested to be put to bed due to feeling tired and hurting, which staff reported was usual after dialysis. Around mid-afternoon, NA #1 went to transfer the resident to bed. NA #1 knew from the Resident Care Guide that a mechanical lift was required but found that the two lifts on her section were not charged and unavailable. Despite this and the resident’s insistence on going to bed, NA #1 attempted a stand-pivot transfer from the wheelchair to the bed without a lift. During this attempt, the resident’s legs gave out, she panicked, and NA #1 lowered her to the floor. NA #1 then independently lifted the resident from the floor back into the wheelchair, where the resident appeared slumped, and adjusted her upright. NA #1 did not notify a nurse at the time of the assisted fall and did not obtain a nurse assessment before moving the resident from the floor to the wheelchair. Shortly thereafter, NA #1 called NA #2 and the Medication Aide to help transfer the resident from the wheelchair to the bed but did not inform them that an assisted fall had occurred. All three staff lifted the resident from the wheelchair to the bed using manual assistance. The Medication Aide later stated she did not call a nurse because she had not witnessed a fall and only saw the resident slumped in the wheelchair. After the transfer to bed, the resident complained of right shoulder pain and requested pain medication, which was administered. The Unit Manager was then notified and, upon arrival, found the resident already in bed, reporting 10/10 right shoulder pain. The Unit Manager and DON later confirmed that facility protocol required that residents not be moved after a fall until a licensed nurse assessed them, and that NA #1, NA #2, and the Medication Aide should not have transferred the resident before that assessment. Later that evening, another nurse noted a large, painful swelling on the resident’s right upper chest, and the resident was sent to the ED, where imaging showed a large right chest wall hematoma with active bleeding.
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