Failure to Prevent Accidents During Mechanical Lift Transfer and Inadequate Emergency Equipment Setup
Penalty
Summary
A deficiency occurred when a resident who was dependent for transfers was being moved using a mechanical lift by two staff members, one of whom was not fully trained or authorized to operate the lift. During the transfer, the sling straps on the left side slipped off the hanger bar as the resident was being lifted, resulting in the resident falling and sustaining left-sided rib fractures and a pneumothorax, which required hospitalization and chest tube placement. The staff involved included a CNA who was orienting and not permitted to provide care, and another CNA who was responsible for the transfer. The facility's policy required two trained staff for mechanical lift transfers, but documentation confirmed that the orienting aide had not completed the required training checklist. Interviews and vendor inspection determined that the lift was functioning properly and that the incident was due to user error, specifically improper attention to strap placement and monitoring during the lift. Another deficiency was identified when a resident with a history of stroke, gastrostomy, and dysphagia was observed in bed with a suction machine at the bedside that was not fully set up. The machine was missing essential components, including the suction canister, tubing, and yankauer, despite a physician order for suctioning as needed for oral secretions. The nurse on duty confirmed that the suction equipment was not ready for use and acknowledged its importance in preventing accidents, especially given the resident's risk for respiratory emergencies due to her medical condition and NPO (nothing by mouth) status. Both deficiencies were substantiated through interviews, record reviews, and direct observation. The first involved a failure to ensure that only trained staff operated mechanical lifts, leading to a serious resident injury. The second involved a failure to provide care consistent with physician orders, leaving a resident at risk in the event of a respiratory emergency due to incomplete setup of emergency equipment.