Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including congestive heart failure, dementia, osteoporosis, and use of blood thinning medication, was transferred using a mechanical lift by a single CNA, contrary to facility policy requiring two staff for such transfers. The resident was later found to have extensive bruising on the right ribs, hip, knee, and ankle, with measurements indicating significant subcutaneous bleeding. The CNA involved admitted to transferring the resident alone and suggested that the lift arm may have pressed against the resident's rib area during the process. The CNA also failed to promptly report the skin changes to nursing staff. Interviews with other CNAs and RNs confirmed that mechanical lift transfers are to be performed by two persons for safety. The resident's physician noted that the pattern of bruising was consistent with an impact against a hard surface, and a CT scan confirmed a subcutaneous bleed without evidence of spontaneous internal bleeding. Facility leadership acknowledged that the incident was avoidable and that the resident likely experienced an impact during the unsupervised transfer.