Failure to Implement Fall-Prevention Measures and Safe Mechanical Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and effectively implement fall-prevention interventions for a resident at high risk for falls. During breakfast observation, the resident was seated forward in a dining chair with her buttocks not against the back of the chair, prompting a CNA to instruct her to scoot back due to safety concerns. The resident was wearing slipper socks that were worn on the bottom, with holes forming and very few grip dots remaining. Upon further inspection, staff acknowledged that the grips were worn off and that it would be safer for the resident to have socks with grips. The resident’s fall risk assessment showed a high-risk score of 15, and the care plan identified her as at risk for falls related to deconditioning and dementia, with an intervention specifying nonslip footwear as tolerated. The DON stated that residents with high fall risk scores should have specific interventions on the care plan that are to be followed. The facility did not have a fall prevention policy and instead had only an Incidents and Accidents policy that applied after an incident occurred. The facility also failed to provide a safe mechanical lift transfer consistent with its own policies and the resident’s care plan. The resident, who had diagnoses including dementia, lack of coordination, Alzheimer’s disease, depression, anxiety disorder, hyperlipidemia, hypertension, hypothyroidism, and sepsis, was documented on the MDS as having severe cognitive impairment, requiring substantial/maximal assistance for rolling in bed, and being dependent for transfers. The care plan specified that the resident required assistance by two staff for transfers and used a mechanical lift. During observation, two CNAs brought the resident to her room for incontinence care, with the resident seated in a wheelchair and a mechanical lift sling under her. After attaching the sling to the lift, one CNA went into the bathroom, and the remaining CNA completed the mechanical lift transfer from wheelchair to bed alone, without assistance. The CNA later stated that facility policy requires two staff for mechanical lift transfers for safety, and the DON confirmed that the mechanical lift policy mandates two staff members—one to maneuver the lift and one to watch and guide the resident—when using a mechanical lift.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.