Failure to Follow Care Plan During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan during a mechanical lift transfer, resulting in the resident sustaining an injury. The resident had severe dementia with agitation, hemiplegia, hemiparesis, muscle weakness, and required substantial assistance with mobility and transfers. The care plan specified interventions for behavioral symptoms, including offering diversion, redirection, calm communication, step-by-step explanations, stopping care if the resident became combative or resistive, and notifying the provider if behaviors increased or persisted. On the evening of the incident, a nurse aide attempted to transfer the resident from a wheelchair to bed using a mechanical lift while the resident was visibly anxious, restless, and flailing their arms. Despite these behaviors, the aide proceeded with the transfer alone, without reporting the behaviors to nursing staff or requesting assistance, as required by the care plan and facility policy. During the transfer, a loop on the lift became detached, causing the resident to tip forward and strike their head on the lift's mast. The aide then completed the transfer without notifying nursing staff of the incident or the resident's behaviors. Later, nursing staff discovered injuries to the resident's head and ear, which were not present earlier in the day. The resident was sent to the emergency department for evaluation, where a forehead hematoma was diagnosed. The incident was initially treated as an injury of unknown origin until the aide reported the details of the transfer. Interviews confirmed that the aide did not follow the prescribed interventions for managing the resident's behaviors and did not adhere to the requirement for two staff during mechanical lift transfers.