Failure to Follow Care Plan for Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive, person-centered care plan for a resident who required assistance with activities of daily living due to quadriplegia and muscle weakness. The resident's care plan specified that all surface-to-surface transfers must be performed using a total mechanical lift with the assistance of two nursing staff members. Despite this, during a bed-to-Geri-recliner transfer, one CNA attempted to transfer the resident alone, without waiting for the second CNA to assist, and did not lock the Geri-recliner or open the base of the lift as required by policy. As a result of these actions, the resident, who was dependent for mobility and transfers and had additional conditions such as colostomy, contractures, paralysis, and pressure ulcers, was observed on the floor with the transfer sling beneath him and the mechanical lift and Geri-recliner overturned. The incident led to the resident sustaining an acute displaced fracture of the left anterolateral rib, as confirmed by hospital imaging. The resident reported pain immediately following the incident and required pain management upon return to the facility. Interviews with facility staff and review of records confirmed that all CNAs had access to care instructions via facility software and had received training on the requirement for two staff members during mechanical lift transfers. Both CNAs involved in the incident acknowledged the policy and their failure to follow it, which directly resulted in the resident's fall and injury. The facility's investigation corroborated that the transfer was performed in violation of established protocols.