Failure to Follow Mechanical Lift Transfer Protocol and Timely Reporting of Resident Fall
Penalty
Summary
A certified nurse aide (CNA) transferred a resident who required two-person assistance with a mechanical sling lift by herself, contrary to the facility's policy and the resident's care plan. During the transfer, the resident fell from the lift onto the floor. The CNA did not immediately report the fall to nursing staff, nor did she wait for a nurse to assess the resident before moving them. Instead, she physically lifted the resident from the floor and placed them back in bed without notifying anyone of the incident. After the resident was returned to bed, the CNA still did not inform nursing staff about the fall or the presence of blood on the resident's head. The resident remained in bed for over two and a half hours, during which time he was found to be bleeding from a head wound and was complaining of severe pain. The incident was only discovered when a family member noticed blood during a video call and alerted staff, prompting further assessment and eventual transfer to the hospital. The resident, who had diagnoses including Parkinson's disease, Alzheimer's disease, osteoarthritis, osteoporosis, and peripheral neuropathy, was subsequently found to have sustained multiple serious injuries, including several fractured ribs, a fractured scapula, spinal fractures, bilateral subdural bleeds, a head laceration, and other internal injuries. The CNA admitted to being aware of the facility's policies regarding mechanical lift transfers and the requirement to report falls but failed to follow them, resulting in a significant delay in care and assessment.