Failure to Investigate and Prevent Recurrence After Mechanical Lift Fall
Penalty
Summary
The facility failed to thoroughly investigate and take preventative action following an avoidable accident involving a resident who was dependent on staff for activities of daily living, including transfers. The resident, who was cognitively intact and required assistance from one to two staff members, reported being dropped from a mechanical lift during a transfer, resulting in a fall onto a shower chair and subsequent pain to the right shoulder and neck. The facility's investigation into the incident did not include an interview with the resident, observations of staff performing mechanical lift transfers, or interviews with other residents and staff who used the mechanical lifts. Additionally, there was no documentation that the mechanical lift was inspected by the Maintenance Director for defects, nor was there any evidence of education provided to the staff involved in the incident to prevent future occurrences. The facility's policy required determination of the cause of falls, proper use and maintenance of assistive devices, and staff training, but these steps were not followed in this case. The Regional Nurse Consultant acknowledged that the investigation was incomplete and lacked necessary preventive measures.