Failure to Provide Adequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a safe environment for Resident #73, who required two-person assistance for bed mobility and mechanical lift transfers. On November 18, 2024, Certified Nursing Assistant #14 independently transferred Resident #73 using a mechanical lift, contrary to the facility's policy and the resident's care plan, which mandated two-person assistance. This action led to an incident where the resident sustained a bruise on the forehead, which was discovered after the transfer. Resident #73, who has Alzheimer's Disease, Cerebral Infarction, and Type 2 Diabetes Mellitus, was admitted with severely impaired cognition and functional limitations in both upper and lower extremities. The resident's care plan and physician's orders clearly documented the need for two-person assistance for transfers due to the resident's increased risk for falls and injuries. Despite this, CNA #14 proceeded with the transfer alone, resulting in the resident's head coming into contact with the mechanical lift bar, causing a lump and a small cut on the forehead. Interviews with various staff members, including CNAs, LPNs, and RNs, confirmed that CNA #14 did not request assistance for the transfer, even though the unit was not short-staffed. The Director of Nursing Services acknowledged that CNA #14 did not adhere to the care plan, which required two-person assistance for mechanical lift transfers, and stated that it was unacceptable for the transfer to be conducted without a second staff member.
Plan Of Correction
Plan of Correction: Approved January 9, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #73 On 11/18/24, the IDCP Team reviewed the resident’s plan of care related to risk for accidents and determined that the resident continues to require two-person assistance with bed mobility and two-person assistance with a mechanical lift for transfer in and out of bed. The Nurse Manager reviewed that plan of care for two-person assist for bed mobility and mechanical lift transfers with unit staff. CNA #14, who completed the mechanical lift transfer without assistance causing the resident to sustain a head injury that required a CT scan was terminated. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The Nurse Managers and IDCP Team will identify all residents who are at risk for an accident through a review of accident risk associated assessments, need for supervision and assistance with ADL care, including all residents who require two-person assist with transfer and a mechanical lift, and have impaired cognitive status. The IDCP Team will review the care plan and CNA Care Instructions for all identified residents to ensure that the care plan and CNA Care Instructions are current and include resident-specific interventions for supervision and assistance, including two-person transfers with a mechanical lift, necessary to prevent an accident. The responsible Nurse Manager/designee will review any changes to the plan of care with the responsible unit staff. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Medical Director, Chief Nursing Officer and Risk Manager will review the facility’s policies and procedures for Accident Prevention, including protocols related to residents who require the use of a mechanical lift with two-person assist for transfers. The Staff Educator/designee will provide general reeducation to all staff regarding Accident Prevention and resident safety. Education for the Nursing staff will also include following the plan of care for residents who require a mechanical lift for transfer with two-person assist. All CNAs will be reeducated on the requirement to review the ADL/Care instructions prior to providing care or transferring a resident. Accident Prevention education will be included in the orientation of all staff and be reviewed annually and as needed. Nursing-specific education on Accident Prevention will be provided during orientation, annually and on an as needed basis. The RN Supervisors and Nurse Managers will continue to monitor for compliance with accident prevention protocols during routine and random rounds and observations of care being provided/transfers being completed to ensure the plan of care is being followed to prevent accidents. Residents who require two-person assistance with a mechanical lift for transfer will be monitored for staff compliance with two-person transfer assist as outlined in the plan of care. The Unit Manager/shift charge nurse will conduct random checks of staff following the plan of care related to two-person assist with a mechanical lift. Immediate corrective actions, such as staff reeducation regarding a two-person transfer/use of a mechanical lift and responsibility to follow the plan of care or updating of the plan of care to prevent an accident when a resident requires a different level of ADL/transfer assistance, will be implemented as needed. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The facility will develop an audit tool to monitor compliance with adhering to the Accident Prevention Policy, including protocols for following the resident’s individual ADL/transfer plan of care for assistance to be provided to prevent accidents. The Nurse Manager/designee will complete 5 random unannounced observation audits to assess compliance with safe provision of care consistent with the ADL/transfer assist instructions weekly x 4 weeks then monthly x 3 months inclusive of all 3 shifts. The ADL/transfer assist instructions will be audited at the same time for accuracy. Residents who require a two-person transfer assist with a mechanical lift will be included in the audit sample. The Risk Manager/designee will audit 15% of all Occurrence Reports on a quarterly basis to determine compliance with Accident Prevention protocols. All findings will be reported to the Administrator. The Risk Manager/Designee will continue to report accident prevention and supervision audit findings to the QAPI Committee, minimally, on a quarterly basis for discussion, evaluation, and follow-up corrective action. The accepted level of compliance is 95%. Completion Date: 01/31/2025 Responsibility: Chief Nursing Officer