Resident Injury Due to Improper Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, atrial fibrillation, congestive heart failure, and pain, who was admitted to hospice care, was transferred using a mechanical lift by only one staff member. The resident's care plan required two staff members to assist with mechanical lift transfers, and the facility's policy also mandated two caregivers for such transfers. During the transfer, the staff member did not properly apply the sling, resulting in the resident being dropped from the lift. As a result of this improper transfer, the resident sustained a displaced fracture to the distal tibia and fibula and required hospital evaluation and treatment. Documentation in the electronic medical record, progress notes, and incident report confirmed that the transfer was performed by a single staff member and that the sling was not adequately secured, directly leading to the resident's fall and injury.