Failure to Thoroughly Assess Resident After Mechanical Lift Incident
Penalty
Summary
A deficiency occurred when staff failed to thoroughly assess a resident for injuries after an incident involving a mechanical lift transfer. The resident, who had severe cognitive impairment, was dependent on staff for all activities of daily living and had a significant medical history including dementia, diabetes, a recent right femur fracture, and a terminal diagnosis of rectal cancer. During a wound care procedure, the resident became restless and managed to remove his arm from the lift sling, resulting in staff lowering him to the floor while his legs remained strapped in the lift. The resident then threw himself to the side before being fully released from the lift. Following the incident, staff assisted the resident back into his wheelchair and noted no immediate signs of pain or injury. However, there was no documentation of a comprehensive injury assessment, such as a range of motion evaluation, being performed at that time. Staff interviews confirmed that only a basic physical check was conducted, and no range of motion assessment was completed. The facility's policy required a thorough assessment for injuries after such incidents, but this was not followed. The following day, a hospice aide reported concerns about the resident's leg, which was then found to be rotated inward. An x-ray revealed a right femur fracture with severe dislocation, and the resident was sent to the hospital for further treatment. The deficiency was identified due to the lack of a thorough post-incident assessment as required by facility policy, despite the presence of multiple staff members during and after the event.