Failure to Provide Timely Assessment and Communication After Mechanical Lift Incident
Penalty
Summary
A deficiency occurred when a resident with multiple comorbidities, including osteoporosis and a history of falls, experienced a significant change in condition following an incident involving a sit-to-stand lift. The resident, who required two staff for transfers per her care plan, was transferred by a single CNA using the lift. During the transfer, the lift's battery died, resulting in the resident being left in a squatting position with her buttocks on the foot pads of the lift. The CNA, acting alone, attempted to move the resident from the compromised position to her wheelchair and then to bed, without waiting for a nurse assessment. This incident resulted in a hip fracture for the resident. Following the incident, staff failed to follow established protocols and professional standards of practice. The event was not immediately or accurately reported to the oncoming shift or to the resident's provider, and critical details such as the change of plane and the resident ending up on the floor were omitted. There was no thorough or timely RN assessment performed after the incident, despite the resident reporting escalating pain levels (up to 9 out of 10) and visible changes in the appearance and positioning of her leg. Vital signs were not obtained or documented at the time of the incident or during subsequent pain episodes, and changes in the resident's condition, such as internal rotation of the lower extremity, were not recorded in the medical record. Communication breakdowns further contributed to the deficiency. The provider was not informed of the true nature of the incident, which delayed appropriate medical intervention and diagnostic testing. Staff interviews revealed a lack of understanding and adherence to post-fall protocols, including the requirement for RN assessment before moving a resident after a fall or change of plane. Documentation was incomplete and delayed, with late entries and missing assessments, and staff failed to ensure that all relevant information was communicated to the provider and documented in the resident's record.