South Valley Post Acute Rehabilitation

implemented of two-person assistance for transfer with staff.

-However, according to the fall care plan, the intervention for Resident #2 to become a two-person assist for transfers with staff was initiated on [DATE].

C.

Staff interviews CNA #5 was interviewed on [DATE] at 2:33 p.m. CNA #5 said she was involved in Resident #2's assisted fall.

She said she prepared to transfer Resident #2 from the bed to the wheelchair.

She said the resident looked wobbly and weak, so she attempted to sit Resident #2 on the bed. CNA #5 said the resident was seated on the edge and had to be assisted to the ground. CNA #5 said Resident #2 was wearing non-slip socks and a gait belt when she attempted to independently transfer the resident from the bed to her chair.

She said Resident #2 usually required one-person staff assistance to transfer.

The DON was interviewed on [DATE] at 2:46 p.m.

The DON said when a fall was sustained by a resident, the staff should try to determine the root cause of the fall with an IDT approach.

She said the initial response should include making sure the resident was safe and could access their call light.

The DON said the care plan should be updated when new interventions.

She said after Resident #2's fall on [DATE] the fall care plan was revised with new interventions, including the two-person assist with transfers.

The DON said she was unable to determine if a two-person transfer occurred at the time of the fall.

The DON was interviewed again on [DATE] at 4:13 p.m.

The DON said CNA #5 transferred Resident #2 independently on [DATE].

She said CNA #5 did not know Resident #2 became a two-person assist with transfers.

She said the new intervention that was implemented after Resident #2's fall on [DATE] of the resident becoming a two person transfer was not transcribed onto the CNA tasks, which led to CNA #5's lack of knowledge of the resident's current transfer status.

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