Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to use a mechanical lift for a dependent resident transfer, as required by the resident's care plan and facility policy. The resident, who had diagnoses including morbid obesity, right knee pain, and osteoarthritis, requested incontinence care and refused the mechanical lift, insisting on a stand and pivot transfer. The CNA, despite knowing the care plan required a mechanical lift with two staff, complied with the resident's request and performed a stand and pivot transfer alone. After the transfer, the resident complained of right leg pain, which led to the discovery of a non-displaced oblique fracture through the lateral plateau of the right tibia and fibula. The resident was subsequently transferred to the hospital and underwent surgery. Interviews with staff revealed that the CNA was aware of the correct transfer method by referencing the care card and acknowledged that she should have informed the nurse of the resident's refusal and sought assistance. Other staff members confirmed that they follow the care card instructions and notify the charge nurse if a resident refuses the recommended transfer method. The Director of Nursing and Administrator both stated that staff are expected to follow the care plan and report refusals to ensure resident safety. The facility's policy mandates the use of mechanical lifts for residents requiring two-person assistance or who cannot be safely transferred by normal techniques, and staff are trained annually on these procedures.