Failure to Use Mechanical Lift Results in Resident Injury During Transfer
Penalty
Summary
A resident with diagnoses including rheumatoid arthritis and osteoporosis, and who was dependent on staff for activities of daily living, was injured during a transfer from a chair to a bed. The resident's care plan and physician's orders specified that a mechanical lift was to be used for all transfers, and this requirement was also documented in the Nurse Aide Pocket Guide. However, on the day of the incident, a CNA transferred the resident without using the mechanical lift because the lift pad was not under the resident and the CNA was unsure how to place it while the resident was in the chair. The CNA proceeded to manually transfer the resident, resulting in the resident's left lower leg being snagged on a piece of the wheelchair, causing a significant skin tear. The injury was severe, with a 14 cm by 5.5 cm skin tear on the left lower leg, continuous bleeding, and a pool of blood on the floor. The resident required emergency medical attention, including a visit to the ER and 19 sutures to close the wound. Documentation indicated that the CNA was aware the resident required a mechanical lift for transfers but did not follow the care plan due to the absence of the lift pad and uncertainty about how to proceed. The CNA also reported that the Pocket Guides, which inform staff of required care, were not available that night due to updates, and she had previously been told by other staff that the resident could be manually lifted. Interviews with other staff indicated that the mechanical lift requirement was consistently listed in the Pocket Guide and that these guides were supposed to be always available. The resident's assessment confirmed severe cognitive impairment and total dependence on staff for transfers. The failure to follow the established care plan and use the mechanical lift directly led to the resident's injury during the transfer.