Failure to Maintain Resident Immobilization After Headfirst Fall During Mechanical Lift Transfer
Penalty
Summary
A resident with a history of cerebral infarction, normal pressure hydrocephalus, aphasia, hemiplegia, contractures, osteoarthritis, osteoporosis, and prior vertebral fractures was dependent on staff for transfers and was prescribed antiplatelet medications increasing her risk of bleeding. During a mechanical lift transfer performed by two nurse aides, the resident slipped out of the sling, fell headfirst to the floor, and struck her head. Immediately after the fall, the resident was found lying supine on the floor, alert but complaining of head and neck pain, as well as left shoulder pain. The nurse on scene assessed the resident, noting her complaints and visible injuries, including a bruise and a skin tear. Despite the resident's complaints of head and neck pain and the mechanism of injury, staff proceeded to move her from the floor back to her bed using the mechanical lift before Emergency Medical Services (EMS) arrived. The staff, including two nurses and two nurse aides, rolled the resident onto the lift pad and transferred her to bed, with one nurse attempting to stabilize her head during the process. The facility did not have a cervical collar available at the time. EMS was called after the transfer, and upon arrival, EMS was informed of the headfirst fall and the resident's complaints. EMS placed a cervical collar and transported the resident to the emergency room. At the hospital, the resident was diagnosed with a C1 cervical vertebra fracture with moderate displacement and associated ligament disruption. She was not a surgical candidate and was transitioned to hospice care, where she later died. The immediate cause of death was listed as complications of blunt force trauma to the neck. Interviews with staff and medical personnel confirmed that the resident was moved prior to EMS assessment, despite her complaints of head and neck pain following a witnessed headfirst fall from a mechanical lift.
Removal Plan
- Reviewed risk management (incident/accident) reports to identify any other incidents involving mechanical lift transfer or falls with major injury, focusing on head or neck injury and inappropriate movement.
- Reviewed all resident transfers to acute care hospital to identify transfers involving serious injury from a fall on the head.
- Reviewed all Facility Reported Incidents to the state agency to identify any incidents involving serious injury from a fall on the head or neck.
- Reviewed the grievance log to identify any complaints of serious injury from a fall on the head or neck.
- Collaborated with the Medical Director to develop education content for Licensed Nurses on appropriate post-fall response actions, including recognizing severity and potential injury.
- Developed education from facility policy and Medical Director direction, emphasizing not moving residents with signs/symptoms of unconsciousness, head/neck pain, tenderness, or deformities, and maintaining alignment while awaiting EMS.
- Educated all Licensed Nurses working on the training developed by the Medical Director for assessing residents, when not to move them, and potential additional injury from moving after a head or neck injury.
- Ensured all newly hired staff will receive this education during orientation.
- Called all nurses not previously educated prior to their next shift to provide education and confirm understanding.
- Maintained a list of staff to confirm education completion.
- Provided written information at each nurses' station.
- In-person education for all nurses on assessing residents, when not to move them, and potential additional injury, to be completed on or before their next shift.
- Educated all Nurse Aides working that when a resident is found down or has a fall/accident, they are not to move the resident and must notify the licensed nurse and wait for instructions.
- Called all Nurse Aides not previously educated to provide education and confirm understanding.
- Ensured all newly hired Nurse Aides will be educated during orientation.
- Licensed Nurses to review with each Nurse Aide at the beginning of each shift for two weeks that they cannot move a resident who has fallen or is found down until the Licensed Nurse assesses the resident.
- Educated Administrative staff, Activities staff, Therapy, Housekeeping, Laundry, Maintenance, and Dietary Departments that no resident can be moved if found on the ground or after a fall/accident, and to notify the licensed nurse immediately.
- Ensured all staff will be educated on or before their next shift; newly hired staff will be educated during orientation.
- Interim DON, Administrator, and Minimum Data Set Nurses to review, five days a week, incident/accident reports, 24-hour report, order listing report for medication changes, discharge report, and grievance log to ensure all falls and injuries from a fall on the head are handled according to the plan.