Failure to Safely Transfer Resident with Mechanical Lift Resulting in Fracture
Penalty
Summary
A deficiency occurred when staff failed to safely transfer a resident with significant mobility impairments using a mechanical lift, resulting in an avoidable injury. The resident had right-sided hemiplegia, right foot drop, osteoporosis, neuropathy, and a history of stroke, making her highly dependent on staff for all transfers and at increased risk for injury. During a transfer from bed to a recliner, two nurse aides operated the mechanical lift, with one controlling the lift and the other guiding the resident. As the resident was being lowered into the recliner, her paralyzed right foot became caught between the footrest and the seat. The resident vocalized pain, prompting the aides to stop the transfer and reposition her foot before completing the transfer. The aides did not immediately report the incident to nursing staff, believing the resident was not injured. Later in the day, during routine care, other staff members observed swelling, redness, and bruising on the resident's right lower leg. The nurse was notified, and upon assessment, pain was noted on palpation of the area. The resident, who had aphasia and diminished pain perception due to neuropathy, was unable to clearly communicate the details of the incident. Diagnostic imaging was ordered, revealing a closed fracture of the proximal right tibia and fibula. The responsible party and physician were notified, and the resident was subsequently sent to the emergency room for evaluation and nonoperative management. Interviews with staff and the Director of Nursing confirmed that the resident's foot had been caught during the transfer and that staff had not adequately monitored the positioning of the resident's extremities during the use of the mechanical lift. The incident was not reported to nursing staff at the time it occurred, delaying assessment and intervention. The resident's medical history of bone fragility and impaired sensation contributed to the severity of the injury and the lack of immediate pain response.