Failure to Provide Adequate Supervision During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident who required two-person assistance for transfers with a mechanical lift was transferred by only one staff member. The resident, who had diagnoses including chronic diastolic heart failure, osteoporosis, and multiple sclerosis, was dependent on staff for all transfers and was severely cognitively impaired. The physician's order and care plan both specified that two staff members were required for mechanical lift transfers. On the morning of the incident, a CNA transferred the resident alone using a mechanical lift. During the transfer, the wheelchair slipped because one side was not locking, causing the resident to land on the armrest of the wheelchair. The CNA corrected the resident's posture and did not notice an injury at the time, nor did he report the incident to a nurse. The resident was later found to have a new bruise and exhibited increased pain during care, which was different from her usual responses. Subsequent assessment and hospital evaluation revealed that the resident had sustained an acute right femoral neck fracture, requiring surgical intervention. The incident was not reported immediately, and the injury was only discovered after the resident displayed signs of pain and a bruise was noticed. The facility's investigation confirmed that the transfer was performed by one staff member instead of the required two, directly leading to the resident's injury.