Resident Injury During Mechanical Lift Transfer Without Physician Order
Penalty
Summary
A deficiency occurred when a resident diagnosed with amyotrophic lateral sclerosis (ALS), who was dependent on staff for activities of daily living, was injured during a transfer from bed to wheelchair using a mechanical lift. The resident, who was cognitively intact and at risk for falls and injuries, was being assisted by four staff members when the mechanical lift tipped to the side as the resident leaned back into the sling. During the process of detaching the sling from the lift, the sling bar struck the resident on the forehead, resulting in pain and subsequent transfer to a general acute care hospital for evaluation and treatment. The resident was found to have head and chest contusions and was treated for pain before returning to the facility. The facility's policy required a physician's order for the use of a mechanical lift, but review of the clinical records revealed that no such order was present for this resident. The Director of Nursing confirmed that the absence of a physician's order and the failure to ensure the resident's safety during the transfer led to the injury. The incident was documented in the resident's care plan and clinical records, and the facility's policy on mechanical lift use was not followed.