F0689

G

Failure to Follow Two‑Person Transfer Requirements Resulting in Fall and Bilateral Ankle Fractures

Long Beach, California Survey Completed on 03-16-2026

Penalty

Fine: $19,135

Summary

The deficiency involves the facility’s failure to ensure a resident who required a two‑person assist with a full body lift for transfers was provided that level of assistance, resulting in an unassisted transfer attempt and a fall. The resident had multiple diagnoses including diabetes mellitus, morbid obesity, extrapyramidal movement disorder, hypotension, neuropathy, generalized weakness, and a history of falls. Her MDS dated 3/1/2026 showed intact cognition and a need for maximal assistance for sit‑to‑stand transfers, and a fall risk evaluation identified her as at moderate risk for falls. A care plan initiated on 6/2/2023, and confirmed as current by the MDS specialist, specified that due to obesity and poor lower extremity strength, the resident was at risk for falls and required safe handling with a full body lift and a two‑person assist for transfers.

On the day of the incident, after the resident was showered, CNA 1 returned her to her room in a shower chair. CNA 1 reported that the resident stood up using a walker next to her bed, holding onto the bed rail, and that the resident would normally pivot to get onto the bed. Instead, the resident suddenly screamed for help and stated her legs felt weak. CNA 1 stated she got behind the resident, called for help, and eased her to the floor, where the resident landed on her bottom with her knees and feet bent. CNA 1 acknowledged that she had been working with this resident for four years and usually assisted her alone during transfers because the resident was often able to walk and help with transfers. CNA 1 also stated she was not aware that the resident’s care plan required a two‑person assist with transfers.

Following the fall, an SBAR documented that after the transfer from chair to bed, both of the resident’s legs became weak and she was eased to the floor. Later that day, the resident complained of bilateral leg pain and had swelling and bluish discoloration of the right ankle. She was transferred to a general acute care hospital, where ED documentation indicated she reported falling when getting out of her shower chair that morning and was found to have significant swelling and ecchymosis of the right ankle and likely swelling of the left ankle. Radiology and orthopedic notes confirmed displaced distal fibular fractures and bilateral bimalleolar fractures of both ankles. The DON stated CNA 1 should have requested assistance for the transfer and that licensed nurses should have communicated the resident’s need for a two‑person assist during transfers. The facility’s falls and fall risk policy required staff to identify and implement resident‑centered interventions based on risk factors such as lower extremity weakness and functional impairments, which were present in this resident.