A resident of Portage Point Nursing home suffered a fall that led to her death due to inadequate supervision during a transfer. The resident was severely impaired on a mental and physical level and required extensive assistance for transfers and general stability. Her care plan stated that she needed two or more people for transfers and could not be left alone in the bathroom as she was also a high fall risk.

On the day of her fall, the CNA (Certified Nursing Assistant) left the resident unobserved in the bathroom while she went to find her gait belt, which is a support belt used for balance. The CNA stated in the report that resident “reached for the grab bar, grabbed it and pulled herself up. I looked and she was falling. By the time I got to her, she was on the floor.”

The resident’s legs were broken above the knee. She was transferred to the emergency unit where she died the next day.

If the CNA had all equipment necessary for the transfer, and had enough people to help as required by the care plan, she would have not left the resident unobserved. Such preventative measures could have spared this resident from unnecessary suffering.