Unsafe Transfer by Activity Aide Leads to Resident Fall and Serious Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement safe transfer and supervision practices during a wheelchair-to-standing and return-to-sitting transfer, resulting in a resident fall with serious injuries. An activity aide (V6) reported witnessing the resident ambulating while pushing his wheelchair, then taking the wheelchair from the resident, turning it around, placing it behind him, and verbally instructing him to sit. V6 stated she positioned herself behind the wheelchair, did not use a gait belt, and did not stand in front of the resident to control the descent. As the resident attempted to sit, he fell forward, striking his head and face on the floor. The resident sustained a facial laceration, nasal fracture, and a type 2 odontoid (neck) fracture and was hospitalized, later returning to the facility where the family chose hospice care. The resident had multiple medical diagnoses including Alzheimer’s disease, unspecified dementia with agitation, osteoarthritis, cardiomyopathy, heart failure, atrial fibrillation, and a history of left foot osteomyelitis with toe amputation. The care plan and MDS indicated the resident had ADL self-care and mobility performance deficits related to dementia and other conditions, and required substantial/max assistance for chair/bed-to-chair transfers, with interventions specifying transfer assistance at a moderate to maximum level with two staff. Physical therapy documentation showed the resident ambulated with minimal assist and wheelchair follow using a front-wheeled walker, and PT later stated that for safe transfer from standing to sitting in a wheelchair, staff should stand in front of the resident, apply a gait belt, and assist back to the wheelchair to prevent frontal falls. The DON confirmed that activity aides were not trained to perform transfers and should call for assistance, and the facility’s fall prevention policy required assessment of fall risk and implementation of appropriate interventions, including determining and addressing factors contributing to falls.
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