Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
Staff failed to use safe and appropriate transfer methods for a resident with significant physical limitations and a history of muscle weakness and bone density disorders. The resident's care plan specified the use of a mechanical lift for all transfers due to his inability to stand and the presence of bilateral plantar flexion contractures. Despite this, staff transferred the resident from a shower chair to his bed manually, with three to four staff members lifting him instead of using the mechanical lift as required by his care plan and facility policy. During the transfer, the resident reported hearing a crack and experienced pain in his right leg. Subsequent assessments by nursing staff documented discoloration, pain, and later, the development of blisters and cellulitis on the right lower leg. An x-ray confirmed a minimally displaced fracture of the right proximal tibia. Interviews with staff, including the ADON and CNAs involved, confirmed that the mechanical lift was not used because the resident often refused it, and staff attempted a manual transfer instead, which was acknowledged by staff as unsafe. The facility's policy on safe lifting and movement of residents required the use of appropriate devices and techniques to ensure safety, and manual lifting was to be eliminated when feasible. Both the Director of Staff Development and the physical therapist stated that more than two staff members should not perform a manual transfer and that the mechanical lift was always the safest option for this resident. The failure to follow the care plan and facility policy directly preceded the resident's injury.