RICHLAND, WA - A nursing assistant at Richland Post Acute attempted to transfer a 230-pound Parkinson's patient alone, causing the resident to fall to the floor despite care plans requiring two-person assistance.
Two-Person Transfer Policy Ignored
The December 26, 2024 incident occurred when a nursing assistant disregarded established protocols for Resident 1, who suffered from Parkinson's disease and severe cognitive impairment. According to the inspection report, the resident's care plan explicitly required two staff members for all transfers and toileting assistance due to their inability to bear weight independently.
Staff A attempted the transfer alone despite clear instructions posted inside the resident's closet door and verbal warnings from the resident's spouse. When the resident's knees buckled during the transfer, the nursing assistant guided them to the floor, where they landed on their knees.
The facility's investigation revealed that Staff A had received incorrect information during shift change, being told the resident only required one person with a gait belt. However, the resident's actual needs were far more intensive due to their medical condition.
Parkinson's Disease Complications
Parkinson's disease affects the central nervous system and significantly impacts movement coordination. Patients typically experience muscle rigidity, tremors, and balance problems that worsen over time. The resident's comprehensive assessment from December 2024 documented severe cognitive loss alongside their movement disorder.
A physical therapist confirmed the resident had poor body control with weakness and fatigue, noting that their head and shoulder would lean to the left side. The resident required significant assistance to stand and needed two staff members for safe mobility.
The post-fall assessment revealed the resident was unable to independently reach a standing position and exhibited loss of balance when standing. They required hands-on assistance for all movement and showed decreased muscle coordination.
Safety Equipment Not Used
The incident was compounded by the nursing assistant's failure to use a gait belt during the transfer. Facility policy required gait belts for any resident who was not independent or had unsteady gait.
Another nursing assistant later had to request a gait belt to safely transfer the resident back to bed following the fall. This detail highlighted that proper safety equipment was readily available but simply not utilized during the initial transfer attempt.
The resident's spouse, who witnessed the incident, reported that Staff A "grabbed the back of the resident's sweat pants" instead of using appropriate transfer techniques. For a resident weighing 230 pounds with severe mobility limitations, this approach created an inherently unsafe situation.
Previous Violations Pattern
This deficiency represents a repeat violation from August 2024, indicating ongoing challenges with fall prevention protocols at the facility. The repeated nature of this citation suggests systemic issues with staff training or supervision regarding transfer procedures.
Federal regulations require nursing homes to maintain environments free from accident hazards and provide adequate supervision to prevent accidents. When facilities fail to follow established care plans, residents face increased risk of injury and diminished quality of life.
Proper Transfer Protocols
Standard nursing home protocols for residents with Parkinson's disease typically involve two-person transfers using mechanical lifts or gait belts. Staff should position themselves on both sides of the resident, maintain clear communication throughout the transfer, and never attempt to catch a falling resident.
The assessment process should evaluate each resident's specific needs based on their medical conditions, cognitive status, and physical capabilities. Care plans must be updated regularly and communicated clearly during shift changes to ensure continuity of safe care.
Medical Consequences
Falls among nursing home residents with Parkinson's disease can result in serious injuries including hip fractures, head trauma, and increased fear of movement. The condition already limits mobility, and additional injuries from preventable falls can accelerate functional decline.
For residents with cognitive impairment, falls may cause confusion and anxiety that affects their willingness to participate in necessary therapies. The psychological impact can be as significant as any physical injuries sustained.
Regulatory Response
The facility received a minimal harm citation affecting few residents, indicating inspectors determined the violation had limited scope. However, the repeat nature of this deficiency may trigger enhanced oversight or additional sanctions if corrective measures prove insufficient.
Nursing homes must submit acceptable plans of correction addressing how they will prevent similar incidents. These plans typically include staff retraining, policy updates, and enhanced supervision procedures for high-risk transfers.
The inspection findings are publicly available and will remain on the facility's record, helping families make informed decisions about care options for their loved ones.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Richland Rehabilitation Center from 2025-01-15 including all violations, facility responses, and corrective action plans.
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