Failure to Follow Mechanical Lift Policy Results in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow both facility policy and manufacturer guidelines for the use of a mechanical lift during the transfer of a resident who was completely dependent on staff for all activities of daily living and mobility. The facility's policy required two trained staff to assist with mechanical lift transfers and to follow the manufacturer's guidelines. However, a certified nursing assistant (CNA) transferred the resident alone, despite knowing the policy, due to a hectic workday and the perception that other staff were unavailable. The CNA also reported that the resident's room was small and not suitable for transferring with both the mechanical lift and the chair present, leading her to move the chair into the hallway and maneuver the resident out of the room by herself. The resident involved had severe cognitive and physical impairments, including anoxic brain damage, hemiplegia, contractures, and was bedbound. The resident was unable to communicate pain verbally and was highly dependent on staff for care. During the transfer, the CNA reported that the resident exhibited jerking movements, but she believed she had prevented the resident from coming into contact with any objects. The CNA also selected a sling for the lift based on her own judgment, without clear guidance or oversight, and there was confusion among staff regarding the compatibility and sizing of slings and lifts. Interviews revealed that staff were not consistently trained or observed in the use of mechanical lifts, and there was a lack of clarity about which slings should be used with which lifts, as well as how to select the appropriate sling size. Following the transfer, the resident was found to have a severely comminuted and displaced fracture of the right femur, which required hospital transfer and treatment. Documentation and interviews indicated that the injury was discovered after staff noticed swelling, warmth, and discoloration of the resident's leg, and the resident exhibited facial expressions of pain. The incident was further complicated by inconsistent training, lack of oversight, and confusion regarding equipment use, as well as the failure to adhere to the facility's own policy requiring two staff for mechanical lift transfers.