Failure to Prevent Accidents Due to Improper Use of Mechanical Lift and Non-Adherence to Care Plans
Penalty
Summary
The facility failed to ensure proper use of a mechanical lift (Hoyer) and adherence to care plan interventions, resulting in significant injuries to two residents. In one instance, a resident with Parkinson's disease and congestive heart failure, who was cognitively intact and required a two-person assist with a Hoyer lift, was being transferred from a raised bed to a shower chair. During the transfer, only three of the four sling straps were attached to the Hoyer, causing the resident to fall headfirst to the floor. The resident sustained a subarachnoid hemorrhage, intraparenchymal hemorrhage, scalp hematoma, and multiple compression fractures in the thoracic and lumbar spine. Staff interviews and observations confirmed that the sling was not properly secured, and the required safety checks were not performed prior to the transfer. In another case, a resident with dementia, weakness, and reduced mobility, who was severely cognitively impaired and required a two-person assist for turning and repositioning, suffered multiple injuries due to improper care. Staff failed to follow the care plan by attempting to provide care alone and not removing a broken, sharp call light clip from the resident's gown. This resulted in a skin tear on the resident's neck, bruising on the chest and right leg, and swelling and bruising on the left hand. Staff interviews revealed that the call light clip caused the skin tear when the blanket was pulled, and the resident was turned and dressed by a single staff member, contrary to the care plan. Both incidents were acknowledged by facility leadership, and documentation confirmed that the care plans and safety protocols were not followed, directly leading to the residents' injuries. The findings were based on observations, staff and resident interviews, and record reviews, which consistently indicated lapses in supervision and failure to prevent accident hazards as required.