Failure to Implement Adaptive Device and Ensure Safe Mechanical Lift Transfers Resulting in Resident Harm
Penalty
Summary
The facility failed to implement a physician-ordered adaptive device for a resident with severe cognitive impairment, resulting in actual harm. The resident, who had dementia and required set up and clean up assistance for meals, had an active physician order for lidded cups for all liquids. Despite this, the resident was provided with hot coffee in a regular cup without a lid, which was not documented on the resident's Kardex. A nurse aide, unaware of the order, placed the coffee in front of the resident and turned away, during which time the resident spilled the hot liquid into her lap, causing multiple burns and blisters to the upper thigh area. The coffee was documented at 139 degrees Fahrenheit at the time of the incident. In a separate incident, the facility failed to ensure that nurse aides demonstrated the necessary skills and competencies to safely perform mechanical lift transfers for another resident with severe cognitive impairment and total dependence for transfers. The resident required a mechanical lift for all transfers per physician order. During a transfer, an agency nurse aide and an agency LPN used a universal sling but failed to cross the leg straps as required by manufacturer instructions. As a result, the resident slid out of the sling, first onto the bed and then onto the floor, striking her head. The resident sustained a scalp hematoma, a left periprosthetic hip fracture, and multiple rib fractures. Documentation revealed that the agency LPN had no evidence of mechanical lift training or competency validation prior to assisting with the transfer. Both incidents demonstrate failures in communication, documentation, and staff competency. In the first case, the adaptive device order was not properly linked to the resident's Kardex, leading to staff being unaware of the requirement. In the second case, improper use of the mechanical lift sling and lack of documented training for agency staff directly resulted in significant injuries to the resident. These failures resulted in actual harm to both residents involved.