Failure to Ensure Safe Transfers, Fall Interventions, and Proper Equipment Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfers, implementation of fall interventions, and provision of appropriate equipment, resulting in accidents for multiple residents. One resident with hemiplegia, COPD, atrial fibrillation, and other conditions, cognitively intact and requiring partial/moderate assistance with wheelchair transfers and showers, slipped and fell in the shower. The resident reported that a CNA did not use a gait belt, transferred her onto a small shower chair without brakes, and the chair moved out from under her during the transfer, causing her to fall onto the shower floor and bruise her side. The CNA later stated she used the small shower chair because the other type was not available, confirmed the chair had no brakes, and acknowledged the resident did not have a gait belt on. Another resident with facial weakness after cerebral infarction, diabetes with CKD, dysphagia, and other diagnoses was identified as high risk for falls and required partial/moderate assistance with transfers. After this resident was found on the floor and reported having tried to get to the bathroom and sliding out of the wheelchair, the root cause was identified as slipping from the wheelchair and an intervention of a non-skid mat to the wheelchair was documented. However, during a later observation of a CNA transferring this resident from bed to wheelchair, no non-skid mat was present on the wheelchair seat, and subsequent inspection by an RN confirmed there was no non-skid mat in the wheelchair or anywhere in the room, indicating the fall intervention was not in place as planned. A third resident with metabolic encephalopathy, pulmonary fibrosis, hemiplegia, chronic respiratory failure, CHF, and repeated falls, who was moderately cognitively impaired and dependent on staff for all mobility and transfers, was observed being transferred via mechanical lift by two CNAs when the lift battery failed, leaving the resident suspended in the air with the lift legs stuck in the closed position. One CNA stated they would have to transfer the resident sideways, then removed her hands from the resident and sling, leaving the resident hanging from the lift without staff support while the other CNA operated the emergency release and the wheelchair was repositioned and tilted to complete the transfer. A fourth resident with dementia, COPD, PVD, prior MI, artificial hip, osteoarthritis, knee pain, and total dependence for ADLs, who was incontinent and care planned for fall risk with interventions including fall mats and keeping the bed in low position, was repeatedly observed in bed with the fall mat folded and stored upright at the head of the bed rather than in use. The administrator stated there was no fall prevention policy, only a statement at the end of another policy, while existing policies required safe transfers using gait belts and lifts and required IDT investigations and implementation of appropriate interventions after accidents.
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