Failure to Provide Adequate Supervision During Mechanical Lift Transfers Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure that residents who required two-person mechanical lift transfers received adequate supervision and assistance, resulting in actual harm to two residents. In the first incident, a resident with diagnoses including heart failure and anxiety, and who was assessed as requiring dependent care from two or more staff for all transfers, was transferred out of bed by a single certified nursing assistant (CNA) using a mechanical lift. During the transfer, the resident fell, sustaining a humerus fracture and facial swelling. The resident reported feeling helpless and scared during the incident. Documentation and interviews confirmed that the CNA performed the transfer alone, contrary to the resident's care plan and facility policy, and did not immediately report the incident to nursing staff. The recreation aide present during a subsequent transfer did not assist and assumed the incident had already been reported. The CNA was later terminated for not following policy. In the second incident, another resident with severe cognitive impairment and hemiparesis, who was also dependent on two or more staff for all activities of daily living, was transferred from bed to chair by a single CNA using a mechanical lift. The CNA attempted the transfer alone after being unable to find assistance, resulting in the resident falling to the floor and sustaining an acute right femur fracture that required surgical intervention. The CNA admitted to transferring the resident alone and not calling for help, despite knowing the requirement for two-person assistance. Another CNA discovered the incident and helped return the resident to bed before notifying the charge nurse. The facility's investigation concluded that the CNA did not follow the resident's plan of care and that there was reasonable cause to believe neglect or mistreatment may have occurred. Both incidents were confirmed through review of medical records, interviews with staff and residents, and facility documentation. The facility's policy required two staff for mechanical lift transfers and immediate reporting of accidents, but these protocols were not followed in either case. The failures resulted in significant injuries to both residents, including fractures and emotional distress, and were attributed to staff actions that disregarded established care plans and facility procedures.