Failure to Use Mechanical Lift for Post-Fall Transfer
Penalty
Summary
A deficiency occurred when staff failed to use a mechanical lift to safely transfer a resident following a fall. The resident, who had a history of osteopenia, femur fracture, gait abnormalities, and moderate cognitive impairment, was found on the floor next to her bed during overnight rounds. The resident's medical records indicated she had range of motion limitations on one side of her body and used a wheelchair for mobility, with no ability to walk. After the fall, the resident was assessed by a nurse and found to have no injuries at that time. Despite facility protocol requiring the use of a mechanical lift for post-fall transfers, three staff members, including a CNA, an RN, and an LPN, manually lifted the resident back into bed. Accounts from the staff confirmed that they either picked up the resident by her upper and lower body or used a blanket as an improvised sling, rather than using the mechanical lift. The Director of Nursing confirmed that bedding is not an approved lifting device and that a mechanical lift should have been used to prevent injury.