Failure to Investigate and Document Injury During Mechanical Lift Transfer
Penalty
Summary
A resident with Alzheimer's disease and dementia, who was non-verbal and dependent on staff for all mobility and transfers, sustained a 2.5-inch laceration on the tip of his penis during a transfer to a bath chair using a total mechanical lift. The incident was witnessed by two CNAs, and the injury was documented by an LPN, who noted the difficulty in bandaging the area and that the physician and POA were notified. However, there was no documentation detailing how the injury specifically occurred, which staff were involved, or whether the transfer was performed safely. The resident's medical record indicated ongoing assessments of the wound, but lacked an incident report or investigation at the time of the event. The Director of Nursing (DON) did not initially believe an investigation was necessary and did not interview the staff involved until prompted later. The facility's policies required that injuries such as bruises, abrasions, skin tears, or lacerations be investigated, and that incident reports be completed and reviewed by administration. Despite this, no investigation or incident report was completed at the time of the injury, and there was no documentation of the CNAs' competencies in using the mechanical lift. The DON later acknowledged that an investigation could have ruled out abuse or neglect, but this was not done in accordance with facility policy.