Improper Use of Mechanical Lift Causes Resident Injury
Penalty
Summary
The facility failed to implement effective safety measures during a transfer, resulting in an injury to a resident. Resident 157, who was admitted with diagnoses including arthritis and morbid obesity, required extensive assistance with mobility and transfers. The care plan specified the use of a mechanical lift with two staff members for all transfers. However, during a transfer to a bariatric bed with a new air mattress, the resident sustained a forehead laceration. The incident occurred when Employee 1 and Employee 2 were transferring Resident 157 using a mechanical lift. During the transfer, the leg of the lift got caught between the wheels of the bed, causing the lift to tip over. Employee 2 attempted to stabilize the situation, but the lift hit Resident 157 in the head, resulting in a laceration. The resident was subsequently evaluated at an emergency department, where a head CT scan was performed and found to be negative. Interviews and facility investigation confirmed that the injury was due to improper placement and use of the mechanical lift. Both employees involved had satisfactory transfer skills and knowledge, yet the incident still occurred. The Nursing Home Administrator acknowledged the facility's responsibility to ensure safety measures were in place to prevent such accidents.
Plan Of Correction
Past noncompliance: no plan of correction required. To monitor and maintain ongoing compliance, the DON/designee audits and assesses 5 residents weekly x 4 to ensure proper lift technique is used during transfers and air mattresses are inflated without issues. Any negative findings will be immediately corrected. Results of audits will be forwarded to facility QAPI for review and recommendation as indicated. The facility's immediate corrective action plan was completed on September 2, 2024. 28 Pa. Code 211.18 (e)(1) Management. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.