Failure to Use Correct Mechanical Lift Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living due to significant right-sided weakness and hemiplegia, was transferred using an incorrect mechanical lifting device. The resident's care plan and physician orders specified the use of a sling lift with the assistance of two staff members for all transfers. However, a CNA transferred the resident using a sit-to-stand lift, contrary to the documented requirements. The CNA was unsure of the correct transfer method and relied on the resident's verbal input rather than consulting the Kardex or care plan, which clearly indicated the need for a sling lift. During the transfer back to the wheelchair, the resident experienced a syncopal episode and was lowered into the chair. Immediately following the incident, the resident complained of right shoulder pain. Subsequent assessment and imaging revealed an impacted fracture of the right humeral neck. The incident was not witnessed by the nurse on duty, but the nurse responded promptly to the resident's complaints and initiated appropriate medical evaluation and notification procedures. Interviews with facility staff revealed that the expectation was for all staff to reference the Kardex or consult nursing staff if unsure about a resident's transfer needs. The facility's policy required mechanical lifts for residents needing two-person assistance and prohibited manual lifting except in emergencies. The CNA involved had not verified the transfer requirements in the resident's records, leading to the use of an inappropriate lift and resulting in injury.