Failure to Protect Resident During Mechanical Lift Transfer Results in Injury
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent for transfers due to a history of cerebral infarction and spinal stenosis, was being transferred from bed to wheelchair using a mechanical lift by two CNAs. During the transfer, the resident's left foot struck the mast of the mechanical lift, resulting in an acute fracture of the third digit proximal phalanx. The CNAs failed to protect the resident's feet during the transfer, and did not immediately report the incident to the charge nurse, despite the resident expressing pain and showing signs of injury. The resident later reported severe pain to an Occupational Therapy Assistant (OTA) during therapy, who observed bruising and escalated the concern to the Director of Rehabilitation (DOR) and then to the LVN. The LVN assessed the resident, noted discoloration, and notified the nurse practitioner, who ordered x-rays confirming the fracture. Interviews revealed that both CNAs involved in the transfer did not consider the incident significant enough to report at the time, even though the resident had expressed discomfort and grunted when her foot was injured. Further review found that the facility did not have a policy on mechanical lift use, and staff had not consistently reported changes in resident condition as required. The lack of a mechanical lift policy and failure to ensure adequate supervision and protection during transfers contributed to the accident and subsequent injury. These failures placed residents at risk of injury due to inadequate hazard prevention and supervision.