Failure to Ensure Safe Mechanical Lift Transfer and Fall Prevention
Penalty
Summary
The facility failed to implement and operationalize policies and procedures to ensure safe transfer of a dependent resident using a mechanical lift, and did not ensure that planned interventions for fall prevention were in place. During a transfer using a mechanical lift, a resident with severe cognitive impairment, dementia, and significant physical limitations fell from the lift, resulting in a laceration to the forehead and an intraventricular hemorrhage. The incident occurred while two CNAs were transferring the resident from a Broda chair to bed using an Invacare 450 mechanical lift with a mesh sling. The resident slipped out of the side gap of the sling, hit their head on the metal bar of the lift, and landed on the floor. Staff interviews and demonstrations revealed that the lift and sling combination allowed for significant tipping and instability, and that the resident, who lacked core strength, was unable to support themselves during the transfer. The facility did not have a written policy or procedure for mechanical lift and sling use, relying instead on the manufacturer's guide, which was not accessible to staff. Staff training was limited to a competency check-off at hire, and there was no evidence of ongoing or refresher training. The care plan for the resident included a general intervention to follow the guide for sling type and loop attachment, but did not provide specific, individualized instructions or precautions. The investigation into the incident lacked statements from all involved staff, and the root cause of the fall was not clearly identified. The facility's documentation and staff interviews indicated confusion and inconsistency regarding how the fall occurred and what factors contributed to the resident slipping out of the sling. Following the fall, the resident experienced a significant decline in condition, including loss of ability to interact, make eye contact, or participate in activities as before. The injury was initially treated with steri-strips, but continued to bleed, requiring a pressure dressing by hospice staff. Diagnostic imaging confirmed an intracranial hemorrhage. The facility did not report the fall with severe injury to the State Agency as required. The lack of clear policies, inadequate staff training, and failure to ensure safe equipment and individualized care planning directly contributed to the resident's fall and subsequent injury.