Unsafe Mechanical Lift Transfer Resulting in Fatal Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to provide a safe transfer for a resident with significant physical impairments, including left foot drop, hemiplegia, and hemiparesis, who was also on antiplatelet medications. During a mechanical lift transfer, two nurse aides did not ensure that the resident's feet, which had shoes on, cleared the bed while being lifted. As the lift was moved, the resident's feet became caught on the mattress, and when they came loose, the resident swung and fell headfirst out of the sling from a height of approximately four feet, resulting in a C1 cervical vertebra fracture. The resident was subsequently transferred to the emergency department, placed in a cervical collar, and later transitioned to hospice care, where she died from complications of blunt force trauma to the neck. The incident was witnessed and documented by staff, with both nurse aides involved providing statements and interviews. One aide turned away from the resident to prepare the wheelchair, leaving the resident unsupervised and without physical support during the lift. The other aide continued to move the lift even after noticing the resident's foot was caught, failing to stop or seek assistance to guide the resident's legs. Neither aide maintained hands-on contact with the resident during the transfer, contrary to manufacturer instructions and facility policy, which require two staff to actively assist and ensure the resident is elevated high enough to clear the bed before moving the lift. Observations and interviews confirmed that the mechanical lift and sling were used, but the process deviated from both manufacturer guidelines and facility policy. The resident's care plan specified total assist by two staff for transfers using a mechanical lift, and the facility's policy required staff to follow manufacturer recommendations. Despite these requirements, the staff did not ensure the resident's safety during the transfer, directly leading to the fall and subsequent fatal injury.
Removal Plan
- Assess Resident #1's post-fall condition and transfer to the emergency department for evaluation and treatment.
- Update Resident #1's care plan to reflect the fall, interventions, and injuries.
- Notify the Interim Director of Nursing, Administrator, Corporate Director of Clinical Services, and Corporate Director of Operations of the incident.
- Initiate investigation, including suspension of both Nurse Aides involved in the transfer.
- Reenact the incident with both Nurse Aides to establish consistency in the description of events.
- Remove and review the lift and sling used during the incident by the Maintenance Director for function and quality.
- Examine all facility lifts and slings for function and quality per manufacturer guidelines.
- Review current residents and care plans to identify those requiring lift transfers and update as needed.
- Review risk management reports to confirm no other incidents involving mechanical lift transfers occurred.
- Review personnel files and facility grievance logs for both Nurse Aides to identify any prior disciplinary action or similar events.
- Educate all Nurse Aides on safe transfer processes based on manufacturer instructions and facility guidelines, including always having an actively assisting partner, appropriate sling selection, correct positioning, secure placement, confirmation of lift base legs spread, and confirmation of sling straps before moving the lift.
- Validate competency for Nurse Aides on lift transfers.
- Include lift transfer education and competency in new Nurse Aide orientation.
- Educate Licensed Nurses on proper transfer processes and observation requirements for Nurse Aide transfers.
- Provide training for Licensed Nurses.
- Include lift transfer education in new Licensed Nurse orientation.
- Provide lift competency training for all Licensed Nurses, including demonstration of safe transfer process using a manikin.