Failure to Use Mechanical Lift After Resident Fall
Penalty
Summary
Staff failed to follow established fall management safety protocols when a resident with multiple medical conditions, including a recent non-displaced fracture of the left femur, experienced an unwitnessed fall in their room. After the fall, the nurse and a CNA manually lifted the resident from the floor and transferred them to a wheelchair without using a mechanical lift, as required by facility policy. The resident was assessed by the nurse and denied pain at the time of the incident. Facility records, including progress notes, incident logs, and staff disciplinary forms, confirm that the mechanical lift was not used during the transfer. Both staff members involved acknowledged not following the protocol, and the DON verified that the facility's fall management policy mandates the use of a mechanical lift for resident transfers after a fall. The deficiency was identified through record review and staff interviews.