Resident Fracture Due to Improper Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident was not safely transferred using a mechanical sit-to-stand lift, resulting in the resident sustaining a proximal tibia and fibula fracture of the right leg. The incident began when a CNA was assisting the resident to use the toilet with the lift. After the resident had a large bowel movement, she became unresponsive while being cleaned and transferred. The CNA called for assistance, and additional staff responded. During this time, the lift failed to lower the resident, and the emergency release button was also not functioning. Staff attempted to lower the resident manually while the nurse tried to operate the lift controls. Observations from staff interviews revealed that the resident's right leg was off the platform, the leg strap was either loose or removed, and the resident was not fully secured in the lift. The resident's leg was positioned awkwardly, and staff were concerned about causing further injury while lowering her to the floor. Despite these concerns, the resident was slowly lowered to the ground, during which her right lower leg was bent and under her body. After being placed on the floor, the resident was found to have a bruise and abrasion on her right shin, and subsequent assessment confirmed a fracture. Facility policy and staff statements indicated that residents should be securely fastened in the lift, with straps snugly applied and feet placed flat on the platform. Proper procedure was not followed, as the resident was not adequately secured, and her leg was able to come off the platform. The failure to ensure the resident was safely transferred and properly secured in the mechanical lift directly led to the injury.