Failure to Provide Safe Assistance During Transfers and Bed Care Resulting in Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents at high risk for falls were provided safe assistance during care, resulting in falls. One resident with COPD, emphysema, dementia, abnormal gait and posture, muscle weakness, and severe cognitive impairment was assessed as dependent for bed mobility, transfers, and mobility, and identified as high risk for falls. Her care plan included use of a bedside floor mat and placement in supervised areas during restlessness. Despite these needs and interventions, the resident experienced multiple falls, including a witnessed fall in which she was left unattended on her side in bed with the bed elevated while a CNA left the room to obtain a clean brief, after having moved the bedside floor mat away to dry. During this incident, the CNA changed the resident’s brief, placed it on the bedside floor mat, then cleaned and moved the mat aside to dry. The CNA then left the bedside to get a clean brief while the resident remained on her side in bed with the bed elevated and without the floor mat in place. The resident turned and fell out of bed, sustaining a 4 cm laceration to the right forehead that required sutures. Facility documentation of the fall investigation identified that the resident had been left unattended inappropriately and that the root cause of the fall was the CNA leaving the resident on her right side with the bed elevated. A second resident, with diagnoses including cerebral infarction with hemiplegia, dysphagia, muscle weakness, CHF, osteoarthritis, obesity, hypotension, hypertension, and moderate cognitive impairment, was also assessed as dependent for chair-to-bed transfers and at high risk for falls. Her care plan included anticipating and meeting needs, ensuring the call light was within reach, encouraging non-slip footwear, and keeping commonly used items within reach. Despite this, a CNA used a sit-to-stand lift alone to transfer the resident, contrary to the required assistance and technique, resulting in the resident sliding out of the sit-to-stand device. The fall investigation identified that the sit-to-stand lift had been operated by only one person, and this was documented as the root cause of the fall, although the resident did not sustain injuries.
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.