Failure to Ensure Safe Use of Lifts and Staff Competency Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff were properly trained, competent, and supervised in the safe use of manual and mechanical lifts, resulting in an avoidable accident involving a resident with obesity, a history of multiple strokes, and significant functional limitations. The resident, who was cognitively intact but physically dependent, sustained a left heel bone fracture after her foot became trapped between the lift and her wheelchair during a transfer. The resident reported that her foot was not correctly positioned on the lift, and despite voicing this to staff, her concerns were not addressed, leading to the injury. Review of staff files revealed a lack of documentation for training or competency assessments related to the use of manual and mechanical lifts. The CNA involved in the incident had not received lift training in seven years, and her previous competency assessment was incomplete and unsigned. Other staff files also lacked evidence of lift training or competency evaluations. Observations of additional transfers showed improper use of the lifts, such as residents' feet not being fully supported on the footrests, and the continued use of a worn and damaged sling, contrary to manufacturer instructions and facility policy. The facility did not conduct a timely or thorough investigation of the incident. Key staff, including the DON and Administrator, were unaware of the injury until days later, and initial incident documentation and interviews were incomplete or missing. The therapy department's assessments of residents' transfer abilities were based on staff interviews rather than direct observation, and there was no documentation that residents' abilities to use the lifts were properly evaluated. These failures placed all residents requiring lift transfers at risk of serious harm and resulted in a determination of Immediate Jeopardy.