Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all surface-to-surface transfers and required the use of a mechanical lift with two-person assistance, was transferred without the use of the required mechanical lift. The resident had significant medical conditions, including hemiplegia affecting the right side, cerebral infarction, and end stage renal disease, and was assessed as a high fall risk. Facility records, including the Minimum Data Set and a facility-provided record, indicated that the resident's transfer protocol required a Hoyer lift and two-person assistance. On the day of the incident, the resident complained of new left leg pain and swelling, which was assessed by nursing staff. The resident reported to staff that a male staff member had transferred her without the Hoyer lift, and this was confirmed by interviews with the CNA and LVN involved. The resident's leg was found to be swollen, warm, and later developed significant bruising. Medical evaluation and imaging at a general acute care hospital revealed a left knee fracture involving the anterior tibial tuberosity and patellar tendon, with severe swelling and moderate effusion. Interviews with facility staff, including the CNA, LVN, RN, and Administrator, confirmed that the resident was transferred improperly, without the required mechanical lift and two-person assistance, which was not in accordance with the facility's policies and procedures. The improper transfer was identified as the cause of the resident's fracture, and the event resulted in the resident's transfer to the hospital for further evaluation and treatment.