Failure to Provide Required Staff Assistance During Mechanical Lift Transfer Resulting 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 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 training, the CNA proceeded alone, citing short staffing as the reason for not seeking help. During the transfer, the upper left clip of the sling detached from the lift, causing the resident to fall approximately four feet to the floor. 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 subsequently transferred to the hospital for evaluation and treatment. Interviews and record reviews confirmed that the CNA was aware of both the resident's needs and facility policy but did not request assistance. Other staff members, including a nurse and another CNA, were present on the unit and available to assist. The staffing schedule indicated adequate staffing levels at the time of the incident. The incident was not immediately reported to nursing staff, and the resident was not assessed by a nurse until later, after signs of injury were observed.