Failure to Use Mechanical Lift Results in Resident Fracture During Transfer
Penalty
Summary
A deficiency occurred when two CNAs failed to follow the care plan for a resident who required a mechanical lift with two staff for transfers due to muscle weakness, difficulty walking, and congestive heart failure. Instead, the CNAs attempted a two-person manual transfer from the bed to a shower chair, despite clear care indicators posted outside the resident's door and documented in the care plan. During the transfer, the resident's right leg gave out, and the CNAs, along with a family member present, assisted the resident to the floor. The mechanical lift was not used until after the resident was already on the floor. The incident was witnessed by a family member, and both CNAs later stated in interviews that they did not check the care indicators or the resident's care plan before proceeding with the transfer. Both CNAs acknowledged they had been trained on the facility's transfer protocols and the use of mechanical lifts, and that there was no reason to deviate from the prescribed method. The resident was subsequently assessed by nursing staff and transported to the hospital, where imaging revealed an acute traumatic fracture of the right distal femur. Facility records confirmed that the care plan and care indicators had been in place and that staff had been inserviced on their use prior to the incident. Interviews with administrative and nursing leadership confirmed that the expectation was for staff to follow the care plan and posted indicators for all transfers. The failure to use the mechanical lift as required directly led to the resident sustaining a significant injury during the transfer.