Mechanical Lift Left in Hallway Causes Resident Fall
Penalty
Summary
A deficiency occurred when a mechanical lift, not in use, was left unattended in the hallway by a staff member. This created an accident hazard, resulting in a cognitively impaired resident with Alzheimer's disease, dementia, agitation, and a history of falls, tripping over the lift while ambulating independently. The resident had poor safety awareness, impaired memory, confusion, and was at high risk for falls, as documented in her care plan and assessments. The incident led to a minor injury, with the resident sustaining a small amount of blood from her left nostril after the fall. Staff interviews and record reviews confirmed that the mechanical lift was supposed to be stored in the utility room when not in use, and that staff had been educated on fall hazards and the importance of maintaining clear hallways. Despite these protocols, the lift was left in the hallway, directly contributing to the resident's fall. The resident continued to ambulate independently and required frequent redirection due to her severe cognitive impairment and impulsivity.