F0689

D

Failure to Update Transfer Status and Rehab Screening After Multiple Stand-Aid Falls

North Smithfield, Rhode Island Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate assistive devices and supervision to prevent accidents for a resident who used a stand aid for transfers. The facility’s Falls Prevention & Management policy and post-fall guidelines required submission of rehab screens after falls for residents not on hospice and communication of changes in status to the interdisciplinary team. Resident ID #165, admitted in 2018 with hemiplegia/hemiparesis following cerebrovascular disease, partial traumatic amputation of the left foot, and vascular dementia, was non-ambulatory and dependent on staff for all transfers, with intact cognition per a recent MDS. Progress notes documented multiple stand-aid related incidents: on 10/17/2025 the resident lost balance and slid to the floor; on 10/31/2025 the resident fell backwards from the stand aid; on 11/1/2025 the resident was noted to be non-compliant with instructions while using the stand aid; on 12/29/2025 the resident was lowered to the floor by two NAs during a stand-aid transfer and was described as non-compliant and at high risk for falling; and on 12/30/2025 the resident was again lowered to the floor when knees buckled during a stand-aid transfer in the shower room.

Despite these repeated falls and documented concerns, record review did not show that rehab screens were submitted after the falls on 10/31/2025, 11/1/2025, 12/29/2025, and 12/30/2025, contrary to the facility’s fall procedure. The Unit Manager RN stated that rehab screens should be submitted after a fall and that all screens are scanned into the EMR, but no such documentation was found. The Director of Rehabilitation confirmed she could not provide evidence that rehab screens were completed following these falls and reported she was unaware that the resident had fallen from the stand aid, had been non-compliant with instructions, or had experienced knee buckling during transfers with the device. This lack of post-fall rehab screening and communication meant that the rehab department was not informed of the resident’s repeated stand-aid related incidents.

Additionally, the facility failed to update and communicate changes in the resident’s transfer status and assistive device needs after a rehab evaluation. Assignment documentation indicated the resident required assistance of 1–2 staff with a stand aid for all transfers, and the fall care plan last revised on 12/30/2025 continued to direct use of a stand aid. After a hospitalization for change in medical status, a rehab evaluation on 1/13/2026 recommended use of a full-body Hoyer lift with two staff for all transfers, documented on a Transfer Status Form signed by OT and PT. The Director of Rehabilitation stated this recommendation was communicated in writing to nursing and that the resident’s whiteboard was updated. However, record review showed the care plan was not revised and the NA assignment sheet was not updated to reflect the new Hoyer lift requirement. The Unit Manager RN acknowledged that the resident’s transfer status had not been updated on the assignment sheet or in the care plan, and the DON acknowledged that rehab screens were not provided after each fall and that the facility failed to clearly communicate the resident’s status to NAs, contributing to ongoing risks during transfers.