Failure to Follow Care Plan for Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) attempted to transfer a resident using a mechanical sling lift without the required assistance of a second staff member, as mandated by both the resident's care plan and facility policy. The resident, who had diagnoses including Parkinson's disease, Alzheimer's disease, osteoarthritis, osteoporosis, and peripheral neuropathy, was care planned to require two staff for all mechanical lift transfers. Despite being aware of this requirement and having received relevant training, the CNA proceeded alone with the transfer. During the transfer, the upper left hook on the sling became disconnected while the resident was suspended approximately four feet above the floor, resulting in the resident falling directly to the ground. The incident was not witnessed by other staff, and the CNA did not request assistance prior to or during the transfer, despite being reminded by a nurse earlier that two staff were needed for such transfers. Other staff on the unit were available at the time, and the staffing schedule confirmed adequate personnel were present. As a result of the fall, the resident sustained multiple serious injuries, including bilateral subdural bleeds, several rib fractures (some with significant displacement and flail segments), a comminuted and displaced scapula fracture, spinal fractures, a pneumothorax, a hemothorax, and a head laceration. The resident was transferred to the hospital for evaluation and treatment before returning to the facility. The failure to follow the care plan and facility policy directly led to the resident's injuries.