Failure to Prevent Accidents and Ensure Safe Equipment Use
Penalty
Summary
A deficiency occurred when a resident who required a two-person assist with a sit-to-stand lift was transferred by a single CNA, contrary to the resident's care plan and facility policy. During the transfer, the lift lost battery power, resulting in the resident being lowered to a squatting position and ultimately sitting on the ground, constituting a change of plane/fall. The CNA then assisted the resident off the floor and into her wheelchair without notifying a nurse or obtaining an RN assessment as required by facility policy. The incident was not immediately reported to the floor nurse or oncoming shift, and subsequent communication among staff failed to ensure timely notification and assessment. The resident was later found to have sustained an intertrochanteric right femoral fracture as a result of the incident. The facility's policies required two staff members for all mechanical lift transfers and immediate reporting and assessment following any fall or change of plane. However, the CNA involved in the incident did not follow these protocols, and other staff members who became aware of the event also failed to report it promptly. The facility's investigation revealed that the emergency lowering feature of the lift was not well understood or effectively used by staff, and that staff had not received adequate competency checks or training on lift operation and emergency procedures. Additionally, the facility did not follow its own fall prevention and post-fall assessment protocols, as the resident was moved and transferred multiple times without a nurse's assessment. Further deficiencies were identified regarding the charging of motorized wheelchairs and electric patient lifts. Staff routinely charged a resident's motorized wheelchair in her room, despite facility policy requiring charging in a ventilated, approved area outside resident rooms. Electric patient lifts were observed being charged in hallways, which is inconsistent with safety recommendations for sealed lead acid batteries, as outlined in the manufacturer's safety data sheet. Staff interviews confirmed that these practices were standard, and facility leadership was either unaware of or did not express concern about the safety implications of these charging locations.