Kin On Health Care Center

felt Resident 1 may be in pain and gave Resident 1 pain medication and applied a pain-relieving cream on Resident 1's shoulders, neck, and arm after the transfer.In an interview on 08/11/2025 at 11:02 PM, Staff C, stated that on the night of the fall incident (06/08/2025) they found Resident 1 attempting to transfer themselves into the wheelchair.

Staff C stated that they ran to Resident 1 and assisted them onto the floor as Resident1's legs started buckling.

Staff C stated that as they guided Resident 1 down to the floor, Resident 1 grabbed onto the wheelchair brakes causing the chair to unlock, which then caused the wheelchair to roll back as they held onto it.

Staff C stated that Staff D came into the room after hearing Staff C call for help.

Staff C stated that Staff D and Staff E were on each side of the resident, lifting Resident 1 up as Staff C was behind the resident lifting her bottom and guiding the resident onto the bed.

Staff C stated that they usually use a gait belt but did not have a chance to get one since they had to act fast.

Staff C stated that Resident 1 grimaced during the transfer.

Staff C further stated that Resident 1 was quieter than usual the next day, which indicated to Staff C that Resident 1 was in pain.In an interview on 07/08/2025 at 1:30 PM, Staff B, Director of Nursing, stated that they expected the care staff to follow the residents' care plan on how to transfer residents.

Staff B further stated that staff should have used a gait belt with Resident 1 to help minimize injury.In an interview on 07/08/2025 at 3:19 PM, Staff A, Administrator, stated that they expected the care staff to follow the care plan and use the gait belt.Reference: (WAC) 388-97-1060 (3)(g).

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