Unassisted Transfer, Unreported Fall, and Delayed Identification of Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance during a transfer and to timely report and assess a fall, resulting in actual harm to a resident. The resident had vascular dementia with behavioral disturbance, a history of left femur fracture, and major depressive disorder, and was assessed as having severe cognitive impairment and being dependent on staff for all transfers. The resident’s care plan identified a risk for falls related to impaired mobility and required staff assistance with transfers, repositioning, and mobility, as well as notification of the physician and responsible party for all falls. On the evening in question, two CNAs were involved in transferring the resident from a wheelchair to the bed. According to a late-entry nursing note and CNA witness statements, the resident was being pivoted or transferred to the bed when she slipped or slid off the edge of the bed and ended up on the floor. Another CNA reported entering the room and finding the resident on the floor sitting by the bed, then assisting with lifting the resident back into bed and repositioning her with a draw sheet. The RN assigned to the resident that night stated she was not notified of any incident involving the resident. No fall was documented at that time, and the physician and responsible party were not notified as required by the care plan and the facility’s fall and accident management policy. A video recording from the resident’s room showed the resident in a wheelchair near the bed with a female employee at the wheelchair handles and a male employee standing about three feet away. The resident placed her left arm on the bed and appeared to be attempting to transfer herself while staff stood by. The video showed the resident slipping down between the bed and the wheelchair, with no staff attempting to assist her before the fall. After the fall, the male employee briefly reached under the resident’s arms, then stepped away, and the female employee left the room; another male employee later entered and assisted in transferring the resident back to bed. The fall was not reported to facility leadership until days later, when the resident’s family member, who had observed the incident on the room camera and noted the resident’s increasing pain and swelling of the left knee, contacted the facility and requested x‑rays. Subsequent imaging revealed a minimally displaced fracture of the left distal femur, and the resident was sent to the hospital for evaluation and treatment, where nonoperative management was chosen after discussion with the family.
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