Failure to Follow Two-Person Transfer Requirement Resulting in Fatal Fall
Penalty
Summary
Facility staff failed to ensure appropriate interventions were implemented for resident safety when a resident who required a two-person assist for transfers was transferred by a single CNA. The resident had multiple diagnoses, including metabolic encephalopathy, type 2 diabetes mellitus with diabetic kidney disease, congestive heart failure, unspecified dementia, end stage renal disease, unspecified lack of coordination, and muscle weakness. The most recent MDS showed a BIMS score of 8/15, indicating moderately impaired cognition. The resident’s comprehensive person-centered care plan identified a need for assistance with activities of daily living due to chronic disease and specified a two-person assist for transfers. On the day of the incident, the resident was scheduled for dialysis. According to RN interview, the RN assigned to the resident stated that the resident was a two-person assist for transfers and that she had instructed CNA #1 to get assistance to transfer the resident. Shortly thereafter, CNA #1 reported to the RN that the resident was on the floor. The RN went to the room and found the resident lying supine on the floor, bleeding from a laceration to the right eyebrow, and assessed the resident’s vital signs while the nursing supervisor called 911. A progress note documented that the resident fell during transfer from bed to chair with CNA assistance while preparing to go for dialysis. In a witness statement obtained by phone, CNA #1 reported that she had not worked with the resident before but knew how to check transfer status in the Kardex. She stated she did not call for help because she was told the resident was a one-person assist and did not need further assistance. CNA #1 described transferring the resident from the edge of the bed to a wheelchair using a one-person technique and reported that the resident fell when she was repositioning the resident in the chair. The facility’s synopsis of events and final report stated that the resident was listed as a two-person assist, that CNA #1 had access to the resident’s transfer status and had signed off on the Kardex acknowledging awareness of the transfer status, and that despite this, the CNA transferred the resident alone. The incident was categorized as an allegation of neglect, and the facility substantiated that the resident fell during an improperly performed transfer. Following the fall, EMS transported the resident to the emergency department. The ER report documented that the resident fell while being moved out of bed, fell from about three feet, and struck the right side of the head, with vomiting noted en route. CT imaging showed a large acute right-sided subdural hemorrhage with mass effect and midline shift, a smaller acute left-sided subdural hematoma, and scattered subarachnoid hemorrhage. Hospital neurosurgery notes indicated the resident presented with a large right subdural hematoma in the setting of a fall from bed at the skilled nursing facility with head strike, and that the resident was actively dying from the significant head injury. The facility’s synopsis of events recorded that the resident sustained a subarachnoid hemorrhage and subsequently died at the hospital.
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