Improper Mechanical Lift Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident who required assistance with transfers was not properly transferred using a mechanical lift, resulting in a fall and injury. The resident, who had a history of osteopenia, osteoporosis, paraparesis, monoplegia of the right lower limb, obesity, and was dependent on a wheelchair, required substantial to maximum assistance for bed mobility and transfers. The care plan specified that two staff members should assist with transfers using a stand-up lift. However, on the day of the incident, a newly hired CNA responded alone to the resident's call light and attempted to transfer the resident without a second staff member present. During the transfer, the CNA did not properly secure the torso belt or strap the resident's legs, resulting in the resident slipping within the lift. The CNA, appearing flustered, pressed the wrong control button, causing the lift to lower instead of raising the resident. The resident ended up in a crouched position with her right foot bent at an odd angle and was unable to stand back up. The CNA attempted to move the resident onto the bed but was unsuccessful, and additional staff had to be summoned to assist. The resident was ultimately placed on the floor and subsequently diagnosed with a nondisplaced avulsion fracture at the tip of the distal fibula, as well as new right shoulder pain attributed to the incident. The facility's protocol and the mechanical lift safety policy required two trained staff members for all mechanical lift operations, regardless of the manufacturer's general information, which allowed for one caregiver in some circumstances. The CNA had received orientation and signed acknowledgment of this policy, which also outlined disciplinary actions for non-compliance. Despite this, the transfer was attempted by a single CNA, contrary to both facility policy and the resident's care plan, directly leading to the resident's fall and injury.