Failure to Prevent Accidents During Bed Mobility and Mechanical Lift Transfers
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, left-sided hemiparesis and hemiplegia, left above-knee amputation, and other comorbidities fell from her bed during incontinent care. The resident was dependent on staff for bed mobility and toileting, requiring assistance from one to two staff members as indicated in her care plan. On the day of the incident, a single nurse aide provided a bed bath with the bed elevated to waist height. During the process, the resident, who typically held onto the privacy curtain for support, became startled, let go, and rolled off the bed, hitting her head and reporting immediate pain in her right leg. The incident resulted in a right femur fracture, and the resident was transported to the hospital for evaluation and treatment. Interviews with staff and the resident confirmed that only one staff member was present during the bed bath, despite the care plan indicating the need for assistance from two staff members. The nurse aide involved stated that she was familiar with the resident's routine and typically performed care alone, while the Director of Nursing and other staff confirmed that the standard of care required two-person assistance for such tasks. The care plan and Kardex did not consistently reflect the required level of assistance, contributing to the failure to provide adequate supervision and safe care during the incident. A second deficiency involved another resident who was dependent on others for transfers and required a mechanical lift with two staff for safe transfers. During a transfer, two nurse aides attempted to adjust the resident in his chair while he was still attached to the mechanical lift. The lift tipped to the side, and the handle grazed the resident above his left eye, causing a skin tear. Both aides reported that the incident occurred while trying to reposition the resident, and the mechanical lift immediately settled back into position. The incident was reported, and the resident received treatment for the skin tear. The root cause was identified as a failure to remove the sling from the lift prior to repositioning, resulting in the injury.