Failure to Follow Two-Person Transfer and Gait Belt Requirements Resulting in Fall With Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance and supervision during a transfer for a resident who was known to be at high risk for falls and required extensive help. The resident had diagnoses including congestive heart failure, polyneuropathy, difficult ambulation, muscle weakness, and COPD, and was assessed as being at risk for falls. A Lift, Transfer, Reposition Assessment documented that the resident required a two-person substantial/maximal assist for transfers with the use of a gait belt. The care plan and MDS further documented that the resident was cognitively intact but had weakness, poor balance, and was not steady, requiring substantial/maximal physical assistance for all transfers and being unable to stabilize without staff assistance for standing, walking, and surface-to-surface transfers. On the date of the incident, the resident was being assisted to the bathroom by a single CNA, contrary to the documented requirement for a two-person assist and use of a gait belt. The CNA’s witness statement indicated that the resident reported knee pain while being taken to the restroom and was holding onto the bathroom grab bar. The CNA moved the wheelchair and stood behind the resident when the resident began to fall to her side and then fell backward toward another bathroom door. The LPN who responded to the CNA’s request for help found the resident on the bathroom floor, complaining of left knee pain and with multiple abrasions, and assisted the resident back to bed. Subsequent imaging and hospital records showed that the resident sustained a left distal femur fracture and a right hip fracture. The facility’s own QAPI fall investigation documented that the resident fell during transfer to the toilet and sustained a major injury, with a possible root cause identified as the resident’s knee giving out. However, the investigation did not address that the transfer had been performed by only one staff member instead of the required two, and that a gait belt, which was part of the resident’s plan of care, had not been used. During interviews, facility leadership, including the DON, ADON, President of Clinical Operations, and Regional Resource Nurse, confirmed that the CNA had improperly transferred the resident alone and without a gait belt, and that the resident sustained fractures of the right hip and left femur as a result of this transfer. Hospital documentation further described the resident’s condition following the fall. At the first hospital, the resident was found to have a left distal femur fracture and right hip fracture, hypotension without external signs of bleeding, anemia, and acute hypotension, and was transferred to a higher-level trauma center due to suspected internal bleeding of the left thigh. At the second hospital, the resident was treated for hemorrhagic shock and acute on chronic shock, and the left femur fracture was described as pathological due to a combination of osteopenia and trauma. The death certificate and coroner’s report listed the cause of death as medical decline following a left distal femur fracture with surgical therapy as a consequence of a ground-level fall. The facility’s falls/accidents/incidents policy defined an avoidable accident as one in which the facility failed to implement interventions, including adequate supervision and assistive devices, consistent with the resident’s needs and care plan to eliminate or reduce the risk of an accident.
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