Failure to Provide Functional Lift Equipment Resulting in Resident Neglect
Penalty
Summary
The facility failed to ensure the availability of a functioning total mechanical lift or an alternative transfer method for a resident who was fully dependent on such equipment for all transfers. On the day of the incident, the resident was transferred to her wheelchair by therapy staff in the early afternoon. Subsequently, all total lift batteries were found to be uncharged and nonfunctional, leaving the resident unable to be returned to bed for approximately nine hours. Multiple staff interviews confirmed that the issue with the lift batteries had been reported to the Administrator days prior, and replacement batteries had been ordered but had not yet arrived. No manual backup lift or alternative transfer method was available during this period. As a result, the resident, who was totally incontinent and dependent for transfers and toileting, remained in her wheelchair from the afternoon until late at night. During this time, she became saturated with urine and feces, experienced significant pain requiring PRN pain medication, and reported distress over the situation. Staff confirmed that no skin or body assessment was performed after the resident was finally returned to bed by an ambulance service, and there was no documentation of incontinent care during the period she was left in the wheelchair. The resident was cognitively intact and had a history of malignant neoplasm and joint pain, with documented dependence for all transfers and toileting. The incident was corroborated by interviews with the resident, CNAs, LPN, DON, and therapy staff, all of whom acknowledged the lack of functioning equipment and the absence of appropriate assessments or care during and after the event. Facility policy defined neglect as the failure to provide necessary goods and services to avoid harm, pain, or distress, which was not met in this case.