Improper Manual Transfer Without Implementing PT Recommendations Leads to Humerus Fracture
Summary
The facility failed to ensure a resident was transferred safely in accordance with physical therapy recommendations and safe transfer practices, resulting in an arm fracture. The resident had a history of significant orthopedic issues, including a surgically repaired right femur neck fracture and a prior nondisplaced fracture of the right humerus, along with diagnoses such as heart failure, kidney disease, and hyperlipidemia. Following a fall at home on Easter that caused a right hip fracture requiring surgical repair, the resident was readmitted with orders for weight bearing as tolerated to the right lower extremity and with hospital instructions that included no pivoting, no bending the hip beyond 90 degrees, and avoiding low chairs. A physical therapy evaluation on 04/10/26 documented that the resident had poor standing balance, was unable to pivot, and recommended use of a Sara Steady or sit‑to‑stand lift for transfers. However, this recommendation was not converted into physician orders or incorporated into the resident’s care plan, and there was no written communication process between therapy and nursing to ensure implementation of new transfer recommendations. At the time of the incident, the resident’s functional status had declined compared to earlier assessments. The discharge‑return anticipated MDS showed that the resident was now dependent on staff for sit‑to‑stand, bed/chair transfers, toilet transfers, and tub/shower transfers, and the walking section was skipped, indicating increased dependence. Despite this, the active transfer order in the chart had been updated only later to “transfer with two assistance and sit to stand,” and staff continued to perform manual transfers. On 04/12/26, two CNAs attempted to transfer the resident from a wheelchair to a recliner using an under‑arm lifting technique, with one CNA on each side hooking their arms under the resident’s arms. No gait belt was used during this transfer, and the CNAs reported that there was no gait belt available in the room. The resident, who was known by staff to have a history of not bending her legs or assisting with pushing up during transfers, began to slide, panicked, and became “dead weight,” causing staff to bear her full weight under her arms. During this improper manual transfer, both CNAs reported hearing a loud crack or pop from the resident’s right shoulder area, and one CNA felt the shoulder move up as if it dislocated. The resident immediately experienced pain, numbness, and limited range of motion in the right upper extremity. Initial x‑ray of the right shoulder showed no acute fracture or dislocation, but the resident continued to have pain and limited range of motion, and subsequent imaging of the right humerus and surrounding structures the next day revealed an acute mildly angulated fracture of the humeral neck. The DON and therapy staff later confirmed that the resident should have been transferred with a Sara Steady or sit‑to‑stand mechanical lift per the PT’s 04/10/26 recommendation and that a gait belt should have been used for all transfers. The DON also confirmed that the facility had no transfer policy and that she was unaware of the PT’s recommendation until after the incident, as the facility relied on verbal communication in morning meetings and had no written process to ensure therapy recommendations were implemented. These actions and omissions led to the resident being transferred manually without a gait belt and contrary to therapy recommendations, resulting in the humeral fracture. The facility’s internal investigation documented that the root cause of the injury was an unsuccessful transfer when the resident began to slide and staff had to bear all of her weight under her arms. CNA interviews corroborated that they used the under‑arm technique instead of a gait belt and were unaware of the PT’s recommendation for a mechanical lift. The DON confirmed that staff on the date of the incident should have been using a stand‑assist mechanical lift and a gait belt for transfers, and that there was no facility policy on transfers at the time. The survey findings concluded that the facility failed to ensure the environment was free from accident hazards and failed to provide adequate supervision and assistive devices to prevent accidents, as evidenced by the improper transfer that caused the resident’s humeral fracture.
Penalty
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Two residents at risk for falls did not receive required fall prevention interventions as outlined in their care plans. One resident's garbage can was not kept within reach as specified, and another resident's visual reminder to call for assistance was not transferred to her new room. Both lapses were confirmed by staff and observed during the survey, indicating non-compliance with established fall prevention policies.
A resident with a history of falls and multiple medical conditions did not have required fall prevention interventions in place, including a body pillow, a sign to request help, and a bed in the lowest position, as specified in the care plan. These items were missing following a recent room change, and the DON confirmed the interventions had not been implemented as directed.
A resident with multiple chronic conditions sustained a laceration to her foot requiring sutures after contacting a torn and rough footboard while attempting to sit up in bed. The unsafe condition of the footboard was not addressed prior to the incident, and there was no evidence of a system for ongoing maintenance and timely repair of resident equipment to prevent injuries.
A resident with multiple comorbidities and on hospice care, identified as high risk for falls, experienced an unwitnessed fall resulting in a fractured arm and head injury. Despite ongoing behaviors indicating increased fall risk, staff did not update fall risk assessments or care plan interventions after admission, and the bed was found in a high position contrary to recommendations. The facility's failure to provide individualized and effective fall prevention measures led to actual harm.
A resident who was dependent on staff for transfers sustained a head injury and concussion when a Hoyer lift tipped and struck the resident during a transfer to bed. The incident occurred because the lift did not clear the raised bolsters of an air mattress, causing the lift to tip as two CNAs attempted the transfer. The resident required emergency care for a laceration and concussion. Staff interviews and documentation confirmed that the air mattress's design interfered with safe transfer procedures.
Medication and treatment carts were left unlocked and unattended at the nurses' station while an LPN was off the unit and a CNA was serving breakfast in the dining room. Several cognitively impaired residents, all able to ambulate independently and known to wander, had access to the area. Facility policy required carts to be locked when unattended, but this was not followed.
Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for two residents identified as being at risk for falls. For one resident with diagnoses including anoxic brain damage, epilepsy, and major depressive disorder, the care plan required that her garbage can be kept within reach to prevent her from attempting to get up unassisted. Observation revealed that the garbage can was placed out of her reach, and both the resident and the Director of Nursing confirmed that this intervention was not being followed, despite its inclusion in the care plan. Another resident, with diagnoses such as adult failure to thrive, dizziness, hypertension, unspecified dementia, and difficulty walking, had a care plan intervention requiring a visual reminder in her room to call for assistance. Observation found that after the resident was moved to a new room, the visual reminder was not transferred with her. An LPN confirmed that the intervention was not in place in the new room and was unaware of the requirement, even though the sign had been present in the resident's previous room. The facility's policy on managing falls requires staff to implement resident-centered fall prevention plans based on individual risk factors. In both cases, the specific interventions designed to mitigate fall risk were not carried out as documented in the residents' care plans, resulting in non-compliance with the facility's own policies and procedures for fall prevention.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
A deficiency was identified when a resident with a history of falls, cerebrovascular disease, diabetes, seizures, and an absent right great toe did not have fall prevention interventions in place as outlined in their care plan. The resident had experienced three falls over several months, each resulting in new interventions being added to the care plan, such as hanging a sign to ask for help, moving personal items within reach, and using a low bed. The care plan also specified that the bed should be in the lowest position when occupied, a body pillow should be placed on the right side of the bed, personal items should be within reach, and a visual reminder should be present to use the call light for assistance. During an observation of the resident's room with the DON, it was found that the required body pillow and sign were missing, and the bed was not in the low position as specified in the care plan. The DON acknowledged that the resident had recently changed rooms and that the body pillow and sign had not been transferred to the new room. Additionally, the DON stated that she did not believe the resident wanted the bed in the lowest position and intended to update the care plan, but at the time of observation, the interventions were not in place as required.
Failure to Maintain Safe Resident Equipment Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to maintain a resident's bedroom furniture in a safe condition, resulting in an injury. The resident, who had a history of respiratory failure, COPD, and type II diabetes, sustained a laceration to the top of her right foot after her foot came into contact with a torn and rough footboard while she was attempting to sit up in bed. The incident happened in the early morning hours, and the wound required hospital treatment, including the placement of seven sutures. Documentation and interviews confirmed that the footboard was in a state of disrepair at the time of the incident. Further review and staff interviews revealed that the rough patch on the footboard had not been addressed prior to the injury. There was no evidence provided to show that the facility had an effective system in place for the ongoing maintenance and timely repair of resident equipment to prevent such injuries. The resident's medical condition, including significant leg swelling and fragile skin, increased her vulnerability to injury, but the unsafe condition of the footboard was the direct cause of harm.
Failure to Update Fall Risk Interventions Leads to Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate, individualized, and effective fall risk interventions for a resident identified as high risk for falls. The resident, who had multiple diagnoses including atrial fibrillation, anxiety disorder, morbid obesity, and acute kidney failure, was admitted to hospice care and was receiving medications such as morphine and Ativan. Despite being assessed as high risk for falls on admission, no further fall risk assessments were completed until after the resident experienced a fall with injury. The resident's care plan, which initially included fall risk interventions, was not updated to reflect changes in her condition or behaviors that increased her fall risk. Prior to the incident, the resident exhibited terminal agitation, including attempts to get out of bed and remove her clothing. Staff and family members observed these behaviors, and hospice staff recommended keeping the bed in the lowest position. However, on the night of the incident, the resident was found on the floor with her bed in a high position, having sustained a fractured left arm, a laceration to her forehead, and a bruise to her cheek. The bed remote, which controlled the bed's height, was found on the floor next to the resident. There was conflicting information regarding whether staff had entered the room to adjust the bed or provide care prior to the fall. Interviews with facility staff, the administrator, and the DON confirmed that the resident's fall prevention interventions and risk assessments had not been updated since admission, despite her ongoing risk factors and recent behavioral changes. The facility's policy required staff to implement resident-centered fall prevention plans based on current evaluations and data, but this was not done for the resident prior to her fall and injury. The lack of updated assessments and interventions directly contributed to the resident's unwitnessed fall and subsequent harm.
Resident Injured During Unsafe Hoyer Lift Transfer Due to Air Mattress Obstruction
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer for a resident who was dependent on staff for all transfers and required the use of a Hoyer lift. The resident, who had diagnoses including Parkinson's disease with dyskinesia, generalized muscle weakness, and chronic systolic heart failure, was being transferred from a wheelchair to bed using a Hoyer lift by two CNAs. The resident's care plan specified the use of a Hoyer lift with two staff and an air mattress with bolsters was in place on the bed as a pressure relief intervention. During the transfer, the Hoyer lift did not clear the raised bolsters of the air mattress. As the staff maneuvered the resident onto the bed, the lift tipped and the top-heavy part struck the resident on the head, resulting in a laceration and concussion. The incident was witnessed by the two CNAs performing the transfer, and the nurse on duty was called to assess the resident immediately after the injury occurred. The resident was transported to the emergency department, where he received six staples to close the wound and was diagnosed with a concussion. Interviews with staff revealed that the air mattress's height and bolsters interfered with the safe operation of the Hoyer lift, contributing to the tipping incident. The manufacturer's guidelines for the Hoyer lift warned of the risk of tipping and emphasized the need to keep the base widened for stability. The facility's policy required at least two staff for mechanical lift transfers and for staff to ensure resident safety and security during transfers. Despite these guidelines and policies, the transfer was not completed safely, resulting in actual harm to the resident.
Medication and Treatment Carts Left Unlocked and Unattended on Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards when medication and treatment carts were left unlocked and unattended on the locked memory care unit. During an observation, both carts were found unsupervised and unlocked at the nurses' station, with no staff present in the immediate area. The only staff member on the unit at the time, a CNA, was serving breakfast trays in the dining room, while the LPN was downstairs administering medications. This left the medication and treatment carts accessible and out of view of any staff. Medical record reviews confirmed that seven residents on the memory care unit were severely impaired in daily decision-making, ambulatory, and capable of independently moving throughout the unit. Interviews with staff verified that these residents wandered the unit and could open the drawers of the carts. Facility policy required that medication carts be locked when out of sight or unattended, a standard not met during the observed incident.
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