Failure to Report Serious Injury from Improper Mechanical Lift Use
Penalty
Summary
The facility failed to report a serious bodily injury to the State Agency after a resident experienced a fall from a full mechanical lift, resulting in a femur fracture. The incident occurred when two staff members were transferring the resident from bed to a shower chair using the lift, and one loop of the sling handle detached from the lift hook. This caused the resident's right leg to slip out of the sling, leading to a fall onto the floor. The resident, who had intact cognition and diagnoses including colon cancer, a previous left humerus fracture, and hemiplegia, was subsequently transported to the hospital and underwent surgery for the femur fracture. Despite the severity of the injury, the administrator determined that the event was not the result of abuse, neglect, exploitation, or misappropriation, and therefore did not report it to the State Agency. However, a review of the incident video by the DON revealed that the nursing assistants did not follow the manufacturer's instructions when attaching the sling to the lift. Facility policy required reporting all serious injuries, including those considered accidental, if they resulted from improper care or procedures. The incident was not found in the Minnesota Adult Abuse Reporting Center records, indicating it was not reported as required.