Improper Mechanical Lift Use Resulting in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and fully dependent on staff for all activities of daily living, sustained a right distal third spiral femur fracture due to improper use of a mechanical lift during transfer. The resident had multiple diagnoses, including brain damage, weakened bones, and contractures, and required two-person assistance with a mechanical lift for all transfers, as documented in the care plan and Kardex. Despite these requirements, staff interviews and record reviews revealed that the mechanical lift was sometimes operated by a single staff member, particularly during periods of short staffing, contrary to facility policy and the resident's care plan. Multiple staff members, including CNAs and LPNs, admitted or reported witnessing the mechanical lift being used by only one person, with the second staff member sometimes merely standing at the doorway or not present at all. The incident leading to the resident's injury was not directly witnessed, but interviews indicated that the resident was found with a swollen knee, and subsequent x-rays confirmed a displaced femur fracture. The family was informed of the injury after they noticed the swelling, and there was confusion and lack of clear communication from staff regarding the cause of the injury. The facility's policy required two staff for mechanical lift transfers, and staff were aware of this requirement, but it was not consistently followed. Further review revealed inconsistencies in staff training and understanding of manufacturer guidelines for the mechanical lift, particularly regarding whether the wheels should be locked during transfers. Staff in-services had provided conflicting information, and some staff continued to lock the wheels despite manufacturer instructions to leave them unlocked. The facility's accident prevention policy emphasized a culture of safety and adherence to protocols, but the failure to ensure proper supervision and adherence to transfer procedures resulted in harm to the resident.