Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was free from neglect by not utilizing a mechanical lift as planned, resulting in a major injury for a resident. The resident, who had cerebral palsy, dysphagia, contractures, and cerebral infarction, required assistance with activities of daily living and was dependent on staff for transfers. The resident's care plan specified the use of a Hoyer lift for all transfers to ensure safety and prevent injury. On the evening of January 26, 2025, two agency Nurse Aides were providing care to the resident. During this time, the resident began complaining of pain in her right arm, which intensified when her shirt and bra were removed. Despite the resident's care plan requiring the use of a Hoyer lift, the aides failed to use it during the transfer from the wheelchair to the bed. This improper transfer led to a serious injury, an impacted fracture of the right humerus, as confirmed by a mobile x-ray. The facility's internal investigation revealed that both aides had completed training on the proper use of Hoyer lifts and were aware of the facility's abuse and neglect policy. However, they neglected to follow the established protocols, directly leading to the resident's injury. Interviews with the resident and her roommate confirmed that the mechanical lift was not used during the transfer, and the resident experienced significant pain and discomfort as a result.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Upon completion of the facility's investigation, the two nursing assistants, Employee 1 and Employee 2 were DNR (Do Not Rehire) because the CNAs failed to follow the training provided through their certification, agency and facility training regarding proper use of assistive devices for transfers and abuse training. Include on the current nursing assistant Daily CNA Report the names of residents with transfer requirements for the use of lifts, e.g., safety concerns, positioning techniques, and necessary assistive devices. The Daily CNA Report will be signed by the certified nursing assistant and the charge LPN/RN. The report sheets will be given to the RN Supervisor at the end of each shift. All clinical nursing staff will be trained on the proper use of assistive devices for transfers and abuse training. Lift training will focus on hands-on practice and residents with a wide range of limitations. An approved acceptable provider has been selected to direct in-service education for F600. The Interdisciplinary Team will create a list of residents that require the use of assistive lifts for transfers. The facility will implement a system of regular observation of staff, including checking if the correct lift is being used for each resident, proper sling selection and placement, correct operation of the lift, and documenting each lift use, while providing ongoing training and education to staff on safe lift practices and report any concerns regarding lift usage. The Therapy Department will conduct a mandatory education for clinical staff on proper use of assistive devices, including the lifts. Random checks will be conducted by Director of Nursing/designee to ensure proper lift and transfer technique is being followed. All incident reports will be reviewed by the Risk Team to ensure no other evidence of noncompliance of lift usage and/or abuse has occurred. The results of the random audit checks and investigation of incident reports will be presented to QAPI monthly x 12 months.