Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and ensure safe transfer procedures for a resident with paraplegia who was dependent on staff for transfers and required the use of a mechanical lift. The resident's care plan and Kardex indicated the need for staff assistance with transfers and use of a Hoyer lift, but did not specify the required number of staff for mechanical lift transfers. On the day of the incident, a CNA attempted to apply a mechanical lift sling under the resident, who was left sitting on the edge of their power wheelchair. The CNA left the resident unsupervised to seek assistance, during which time the resident slipped from the chair and fell to the floor, sustaining a tibial fracture that required emergency room treatment. Interviews and record reviews revealed that staff were aware that mechanical lift transfers should be performed with two staff members, but this requirement was not documented in the resident's care plan or Kardex. The CNA involved in the incident did not ensure the resident was safely positioned or supervised before leaving the room, and the lack of clear documentation contributed to the unsafe transfer process. The resident reported being left partially off the cushion and unsupervised for approximately ten minutes before falling. Further interviews with staff, including the Resident Care Manager and Director of Nursing, confirmed that the care plan should have specified the need for two-person assistance during mechanical lift transfers. The absence of this information in the care plan and Kardex, combined with the CNA's actions, resulted in an avoidable accident that caused significant harm to the resident.