Failure to Provide Two-Person Assist During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a Certified Nursing Aide (CNA) transferred a resident using a Hoyer lift without the required assistance of a second staff member, contrary to facility policy. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was being transferred from a geri chair to bed. During the transfer, the resident expressed pain and was later found to have significant bruising and swelling on the right leg and knee. An x-ray subsequently revealed a fracture of the distal femoral shaft. The facility's investigation revealed that the CNA initially provided conflicting accounts regarding whether another staff member assisted with the transfer. After multiple interviews, the CNA admitted to performing the transfer alone, which was against the facility's established policy requiring two staff members for mechanical lift transfers. The care plan for the resident specifically indicated the need for two-person assistance with Hoyer lift transfers due to the resident's total dependence and physical limitations. Following the incident, staff observed and documented the resident's injuries, including bruising and swelling, and notified nursing and supervisory staff. There were delays in physician notification and response, as documented in the facility's records, with the physician not immediately responding to the initial notification. The resident was eventually sent for an x-ray and transferred to the hospital after the fracture was confirmed.