Unsafe Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for mobility due to multiple medical conditions including morbid obesity, chronic systolic heart failure, and osteoarthritis, was being transferred from a shower chair to her bed using a mechanical lift. The resident was cognitively intact and required assistance from one to two staff members for transfers, as documented in her care plan and Minimum Data Set. During the transfer, two staff members, an LPN and a CNA, were involved in operating the mechanical lift and guiding the resident. The incident happened when the staff encountered difficulty maneuvering the mechanical lift, particularly with the wheels, while the resident was elevated in the sling. Both staff members reported that the resident's weight became unbalanced during the transfer, specifically when the CNA repositioned the resident's legs while the lift was still in motion. This caused the mechanical lift to tip over, resulting in the resident falling to the floor and the lift striking her on the head, causing a laceration that required two staples. The resident was sent to the emergency room for evaluation and treatment and returned with orders for staple removal in seven days. Interviews with the staff involved and facility leadership confirmed that there was a lack of communication between the LPN and CNA during the transfer, and the resident's weight was close to the mechanical lift's maximum capacity. The facility's investigation and documentation indicated that the unbalanced weight during repositioning and movement of the lift led to the tip-over and subsequent injury. The facility's policy on mechanical lift use emphasized safe lifting principles but did not substitute for manufacturer training or instructions.