Failure to Use Mechanical Lift During Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan and transfer protocols for a resident with significant mobility impairments and cognitive deficits. The resident, who had diagnoses including abnormalities of gait, mobility issues, and Parkinson's disease, was care planned to require a mechanical lift with the assistance of two CNAs for all transfers between bed and wheelchair. Despite this, two CNAs performed a manual pivot transfer without a gait belt or mechanical lift, contrary to the resident's care plan and facility policy. During the transfer, the resident attempted to grab the armrest of the wheelchair, resulting in her left fifth finger being bent against the armrest. The incident led to the resident sustaining a fracture of the distal shaft of the fifth metatarsal in her left hand, as confirmed by X-ray. The resident immediately reported pain, and subsequent assessments noted swelling and sensitivity in the affected area. Interviews with the involved CNAs revealed that they were aware the resident was care planned for mechanical lift transfers but chose not to use the required equipment, believing the resident could stand and transfer without it. Both CNAs described the resident's hand position during the transfer and acknowledged that the injury likely occurred as the resident's finger became caught on the wheelchair armrest. Further review of facility policies and staff interviews confirmed that the resident's care plan and Minimum Data Set (MDS) specified the use of a mechanical lift for transfers. The Director of Nursing and the resident's physician both stated that staff are expected to follow the care plan and use mechanical lifts for residents who require them. The failure to adhere to the established transfer protocol directly resulted in the resident's injury during the transfer process.