Failure to Use Mechanical Lift Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident with paraplegia was transferred safely from bed to a shower chair, resulting in a fall and injury. The resident was dependent for transfers and required the use of a mechanical lift as recommended by the Physical Therapy (PT) department. Despite this, two staff members, a Certified Nursing Assistant (CNA) and a Restorative Nursing Assistant (RNA), attempted to transfer the resident manually without the mechanical lift, contrary to the PT recommendation and facility policy. The resident, who had no cognitive impairment and was able to make her own decisions, insisted on being transferred without the mechanical lift because the sling caused her discomfort. The CNA and RNA attempted the transfer manually, realized the resident was too heavy, and assisted her to the floor. During the transfer, the resident experienced pain and, after being assisted to the floor, was later found to have sustained an acute minimally displaced impacted fracture of the distal left femur. Staff interviews confirmed that the mechanical lift should have been used and that the resident's refusal should have been escalated to nursing supervisors. Further review revealed that the facility did not have a care plan intervention specifying the use of a mechanical lift for this resident, despite the PT and Occupational Therapy (OT) recommendations and the resident's high risk for falls. The staff also failed to follow the facility's policies on mechanical lift use and fall prevention, which require all departments to contribute to fall prevention efforts. The lack of a care plan intervention and failure to follow established procedures directly contributed to the resident's injury during the transfer.