Resident Left Suspended in Mechanical Lift Due to Staff Neglect
Penalty
Summary
A deficiency occurred when a resident with morbid obesity, diabetes type 2, congestive heart failure, limited lower extremity range of motion, and total dependence on staff for transfers was left suspended in a mechanical lift sling during a transfer. The resident's care plan required two staff members to assist with mechanical lift transfers, but on the evening in question, only one agency CNA performed the transfer. During the process, the resident expressed concerns about back pain and the manner in which the transfer was being conducted. The CNA became upset, left the resident elevated in the sling above the shower chair, and exited the room, shutting the door and leaving the resident unable to reach the call light. The resident reported that he called for help for approximately ten minutes before two other staff members responded and completed the transfer. The incident was not documented in the resident's nursing progress notes, and there was no immediate incident report filed. The CNA involved admitted to performing the transfer alone and leaving the resident in the sling, stating he intended to de-escalate the situation. Other staff confirmed that the resident was found suspended in the sling and that the CNA had left the room, but they did not notify management at the time. The facility's abuse prevention and reporting policy prohibits neglect, defined as the failure to provide necessary goods and services to avoid physical harm, pain, or mental anguish. Despite the resident not reporting injury or emotional trauma, the actions of the CNA and the lack of adherence to the care plan and facility policy resulted in a failure to protect the resident from neglect during the transfer process.