Failure to Perform Complete Post-Fall Assessment and Safe Transfer After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide resident-centered care and to follow its own post-fall policy and professional standards when responding to a fall. The facility’s Post Fall Routine policy required that an RN assess the resident for injury and provide emergency treatment as necessary, that all residents be assisted off the floor with a Hoyer lift (with limited supervisory discretion), and that residents be monitored and assessed for injury, including range of motion, before being moved. For the fall event in question, video footage and interviews showed that these requirements were not followed, and that a complete assessment, including full range of motion, was not performed before the resident was manually lifted from the floor and placed in a wheelchair. The resident involved had Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, as well as anxiety. The MDS documented that the resident could be understood, could understand others, and had intact cognition for daily decision-making. The resident’s care plans addressed falls, vision, and activity participation, including interventions such as investigating the cause of falls immediately, providing reality orientation, maintaining the resident in high-profile areas when possible, and reporting unsafe behavior to nursing. On the day of the incident, video footage showed the resident standing unsupervised in their room when a CNA entered without knocking, placed hands on the resident’s arms, and pulled the resident into a wheelchair despite apparent resistance. The CNA repeated this action when the resident stood again, nearly causing a fall as the resident almost missed the wheelchair. The video further showed the CNA pushing the resident in the wheelchair, with the resident attempting to block the front wheel with their foot. The CNA then turned the wheelchair and pulled it backwards into the hallway; while the wheelchair was moving, the resident stood up and fell to the floor onto their side. Contrary to the CNA’s written account, there was no video evidence of the resident grabbing a handrail and pulling themselves from the wheelchair. After the fall, the CNA appeared to throw their hands down and walked away, leaving the resident on the floor alone for approximately two minutes before returning with a Hoyer lift, then again standing away from the resident. An LPN arrived to attend to the resident, followed by the Assistant DON, who spoke with the resident and performed only a limited range of motion assessment on the resident’s arms and had the resident bend their knees. Without documented evidence of a full range of motion assessment, particularly of the legs, the Assistant DON and LPN manually lifted the resident from the floor by the arms and placed them in the wheelchair, instead of using the Hoyer lift as required by policy. Interviews with the DON and Assistant DON confirmed that a full assessment, including range of motion and pain assessment, was expected after a fall and that leaving a resident unattended on the floor for multiple minutes and manually lifting them in this manner was inconsistent with facility expectations and policy.
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.