Failure to Use Stand Lift Safety Features Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to transfer a resident with multiple sclerosis, multidrug-resistant organism, and anxiety diagnoses in a safe manner using a stand lift. The resident was dependent on staff for all transfers and had no prior history of falls. During a transfer from wheelchair to bed, two CNAs attempted to use a stand lift but did not secure the resident with the required safety belt and leg straps, as directed by both the care plan and manufacturer’s instructions. The resident reported feeling dizzy during the transfer, released her grip from the lift handles, and subsequently fell backward to the floor, striking her head and experiencing severe hip pain. Staff statements revealed confusion and inconsistency regarding the use of safety features on the stand lift. One CNA stated that the resident typically declined the use of the safety belt and leg straps, while the other CNA reported being told not to use the safety belt. However, the resident and another CNA both stated that the resident had never refused the use of safety straps, although she had commented that the straps were tight. Documentation in the clinical record did not indicate any refusals by the resident to use the safety belt during transfers prior to the incident. The fall resulted in a significant injury, with the resident sustaining a displaced femur fracture that required surgical intervention. Both involved staff had previously completed training and skills validation for safe transfers but failed to follow established protocols and manufacturer guidelines during the incident. The facility’s investigation and staff interviews confirmed that the safety features of the stand lift were not used as required, directly leading to the resident’s fall and injury.