Failure to Implement Fall Interventions and Safe Mechanical Lift Use
Penalty
Summary
The facility failed to implement required fall prevention interventions and proper use of mechanical lift equipment for two residents. For one resident with a history of stroke resulting in left-sided hemiplegia and hemiparesis, both the care plan and physician's orders specified the use of a long positioning wedge to the left side at all times when in bed. However, during two separate observations, the resident was found in bed without the required wedge in place. Interviews with nursing staff revealed uncertainty about the intervention, and the wedge could not be located in the resident's room. The Assistant Director of Nursing confirmed that the wedge should have been in place but was not. In a separate incident, another resident who was cognitively impaired and required extensive assistance for transfers was observed being moved from the floor to bed using a Hoyer mechanical lift. During this transfer, staff failed to engage the brakes on the lift as required by both facility policy and the manufacturer's instructions, resulting in the lift rolling slightly. Both staff involved and the Director of Nursing confirmed that the brakes should have been engaged during the transfer process.