Failure to Ensure Safe and Competent Use of Lifts Resulting in Resident Injury
Penalty
Summary
Facility administration failed to ensure effective oversight and staff competency in the safe use of manual and mechanical lifts for resident transfers, resulting in a serious injury to a resident with a history of multiple strokes, obesity, and unilateral functional limitations. The resident, who was care planned for a manual sit-to-stand lift, 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 properly positioned on the lift, and despite voicing this to staff, the issue was not corrected. Documentation revealed that the resident was unable to assist with transfers and required extensive staff support, yet staff did not ensure her feet were correctly placed on the lift, directly leading to the injury. The facility did not investigate the incident, failed to document or verify that staff were trained and competent in the use of manual and mechanical lifts, and did not ensure that nursing staff followed facility policies and procedures for incident reporting. Personnel files for multiple CNAs lacked evidence of lift training or competency assessments, and interviews with staff confirmed that some had not received lift training in several years. Observations of other transfers revealed additional unsafe practices, such as residents' feet not being fully on the lift footrest and the use of damaged slings, further indicating a lack of staff competency and oversight. The administration did not maintain an accurate incident log, failed to initiate timely investigations, and did not provide documentation of staff education or reenactments related to the incident. Supervisory staff did not follow up on reports of injury, and incident reporting protocols were not followed. These failures placed all residents requiring lift transfers at risk for serious harm, injury, or death due to improper use of transfer equipment.