Failure to Follow Care Plan for Mechanical Lift Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident who required a mechanical lift for transfers. The resident, who was admitted for rehabilitation and had diagnoses including COPD, cirrhosis, duodenal ulcer, chronic respiratory failure, and low back pain, was assessed as dependent on staff for activities of daily living and at high risk for falls. The care plan and Kardex specified the use of a sit-to-stand mechanical lift for all transfers due to the resident's inability to reliably bear weight. On the night of the incident, two CNAs transferred the resident from the toilet to her wheelchair using a gait belt instead of the required mechanical lift. The decision to use the gait belt was influenced by the resident's previous complaints of discomfort with the mechanical lift and perceived difficulty maneuvering the lift in the bathroom. During the transfer, the resident lost the ability to bear weight in one leg and fell to the floor, resulting in a right femur fracture. The CNAs did not consult with a nurse or follow the care plan instructions prior to changing the transfer method. Interviews and documentation confirmed that the CNAs had received prior training on mechanical lifts and resident transfers, and that the resident's care plan had not been updated to allow for a less supportive transfer method. The incident was reported to nursing staff, and the resident was subsequently evaluated and sent to the hospital, where the fracture was confirmed. The failure to use the mechanical lift as directed in the care plan directly led to the resident's fall and injury.