Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Toe Fracture
Penalty
Summary
A deficiency occurred when a resident, who is cognitively intact and dependent on two staff members for transfers, sustained a displaced fracture to her right great toe during a mechanical lift transfer. The resident reported that, during the transfer from her wheelchair to bed, her foot became caught between the center bars of the lift, resulting in significant pain and bruising. The resident stated that staff usually guide her feet during transfers, but on this occasion, her foot was not properly guided, leading to the injury. The incident was not immediately reported to the nurse on duty, and there was confusion among staff regarding who performed the transfer and who was present in the room at the time of the incident. Interviews with staff revealed that the resident requires a full body mechanical sling lift and cannot transfer herself, with the care plan indicating a two-person assist for transfers. However, staff were unable to clearly identify who performed the transfer or if the required number of staff were present. The resident's injury was later confirmed by radiology as an acute, mildly displaced fracture of the right first proximal phalanx, with associated swelling. Documentation and interviews indicated a lack of adequate supervision and failure to ensure safe transfer practices, resulting in the resident's injury.