Resident Injury Due to Untrained Use of New Mechanical Lift
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers due to diagnoses including amyotrophic lateral sclerosis, muscle weakness, and chronic obstructive pulmonary disease, was injured during a transfer using a new mechanical lift. The resident required two-person assistance and was to be transferred according to facility policy and manufacturer guidelines, which mandated that both staff members be trained on the specific lift in use. However, during the transfer, the mechanical lift tilted and struck the resident's head, resulting in a laceration that required emergency hospital care and staples. Certified Nurse Aides involved in the transfer reported that they had not received in-service training on the new mechanical lift prior to the incident. Both aides described the lift tilting unexpectedly during the transfer, with one aide noting that the base of the lift was not properly expanded and the other stating that the resident was holding onto the bar when the lift began to shake and tilt. The incident was corroborated by the resident, who communicated that one of the aides did not know how to operate the new lift, leading to the bar hitting and cutting their head. Facility records and interviews confirmed that the new mechanical lifts had been assembled and tested by the maintenance team, and that leadership was notified of their arrival. However, the staff involved in the incident had not yet received documented training on the new equipment at the time of the event. The lack of training and unfamiliarity with the new mechanical lift directly contributed to the improper use of the device and the resulting injury to the resident.