Failure to Follow Mechanical Lift Protocols Resulting in Resident Fall
Penalty
Summary
Facility staff failed to provide care and services in accordance with professional standards for one resident with significant physical and cognitive impairments. The resident, who had diagnoses including hemiplegia, dementia, generalized muscle weakness, and a history of falls, was assessed as severely cognitively impaired and dependent on staff for transfers. The resident's care plan specified that transfers should be performed using a mechanical lift with the assistance of two staff members and the correct size lift pad. However, during a transfer from chair to bed, a CNA used a lift pad with four loops instead of the required medium/purple six-loop pad and performed the transfer alone, contrary to facility policy and the resident's care plan. As a result of these actions, the resident slipped through the lift pad and fell to the floor. Staff interviews confirmed that the CNA did not wait for a second staff member and used the incorrect lift pad size. Documentation and staff statements indicated that the correct lift pad size was listed at the nurse's desk and that the unit was not short-staffed at the time of the incident. Facility policy required two staff for mechanical lift transfers and proper sling sizing, but these procedures were not followed, leading to the resident's fall.