Failure to Maintain Safe Environment During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when the facility failed to provide an environment free of accident hazards for a resident with multiple medical conditions, including lymphedema, cellulitis, type 2 diabetes mellitus, and cerebral palsy. The resident was cognitively intact but dependent on staff for mobility and required mechanical lift transfers. During an evening transfer, two CNAs attempted to reposition the resident in her wheelchair to prepare for a mechanical lift transfer. In the process, the resident's left leg went under her bed and struck the exposed, sharp edge of the bed frame, which was missing a protective black cap. The impact caused a skin tear and bleeding on the resident's left lower leg. Staff interviews confirmed that the bed frame's end was not covered and had sharp edges, which directly contributed to the injury. The wound nurse was called in to assess the injury and, after evaluation, recommended that the resident be sent to the local emergency room for further care. The emergency room physician documented a significant skin tear laceration that required one stitch to control bleeding. Facility documentation, including the incident report and staff statements, indicated that the environment was not adequately prepared to prevent accidents, as required by the facility's mechanical lift policy. The missing bed frame cap and the presence of sharp edges created an accident hazard that was not addressed prior to the incident, resulting in the resident's injury during a routine transfer.