Failure to Assess Lift Chair Safety for High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident, identified as having a high fall risk and severely impaired cognition, experienced an unwitnessed fall from a lift chair. The resident was found on the floor in front of the lift chair, which was raised all the way up. She sustained a large hematoma on her forehead, a skin tear and bruise on her right hand, and later complained of neck pain. Subsequent medical evaluation revealed acute nondisplaced fractures of the C2 vertebra, leading to hospitalization for observation, pain control, and a neurosurgery consult. Prior to the fall, no lift chair safety assessment had been documented for the resident, despite her high fall risk and cognitive impairment. The resident's medical record confirmed that she was admitted with these risk factors, and her fall risk assessments consistently identified her as high risk. The lift chair safety assessment was only completed after her return from the hospital, at which point it was determined she required total assistance to operate the lift chair. Interviews with facility staff, including the RN/MDS coordinator, DON, and administrator, confirmed that lift chair safety assessments had not been completed for any residents prior to the incident. The facility's policy required a lift chair safety assessment before use, but this was not followed, resulting in the resident's fall and subsequent injuries.