Failure to Use Required Two-Person Assistance During Mechanical Lift Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to follow established protocols for safe resident transfers, resulting in a fall and serious injury. A resident with multiple diagnoses, including Alzheimer's disease, repeated falls, Parkinson's disease, and muscle weakness, required total assistance for transfers and was care planned to be transferred using a mechanical lift with two staff members. Despite this, a Certified Nursing Aide (CNA) attempted to transfer the resident alone using a mechanical lift, while a Hospitality Aide was present in the room only for one-to-one monitoring and did not assist with the transfer. During the transfer, the resident fell from the lift after a snapping or popping sound was heard, striking his legs and head on the lift and floor. The incident resulted in the resident sustaining a subarachnoid hemorrhage, as confirmed by a CT scan, necessitating transfer to a hospital for higher-level neurological care. Documentation and witness statements confirmed that the CNA did not obtain assistance as required by the resident's care plan and facility policy, which mandates two certified staff for mechanical lift transfers. The resident was later readmitted to the facility after hospital treatment and resolution of the hemorrhage.