Failure to Use Required Mechanical Lift and Assistance During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan and special instructions for a male resident with a history of a wedge compression fracture of the lumbar spine. The resident required the use of a mechanical lift with total assistance by two staff members for all transfers due to his medical condition. Despite these documented requirements, the CNA transferred the resident from bed to wheelchair without using the mechanical lift and without assistance from another staff member. During the transfer, the resident's right ankle was twisted, and he immediately complained of pain. Subsequent assessment by nursing staff noted pain in the right ankle, and an x-ray was ordered, which revealed an acute fracture of the right distal tibia. The resident had a history of osteopenia, further increasing his risk for injury during improper transfers. Interviews with the resident confirmed that the CNA did not use a gait belt or mechanical lift and that this CNA had previously transferred him without the required equipment, unlike other staff who consistently used the mechanical lift. Record reviews and staff interviews indicated that the care plan and electronic care task system clearly specified the need for a mechanical lift and two staff for all transfers for this resident. Other staff members demonstrated knowledge of these requirements and reported using the proper equipment and assistance for transfers. The CNA involved admitted to not following the required procedures during the incident, which directly led to the resident's injury.