Resident Injury During Mechanical Lift Transfer Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, morbid obesity, and significant mobility deficits was injured during a transfer using a mechanical lift. The resident, who was dependent on staff for bed mobility and required two-person assistance for transfers, sustained a skin tear on the right foot after it was caught under the foot pedal of a manual wheelchair during the transfer. The incident happened while two CNAs were transferring the resident from a chair to bed using a Hoyer lift. One CNA was distracted due to interpersonal issues with another staff member and did not notice the resident's foot was caught, resulting in a skin tear with moderate bleeding. The resident's care plan specified the need for two-person assistance, and the transfer was being performed with two staff present, but one was preoccupied and failed to ensure the resident's safety. Further contributing factors included the use of a manual wheelchair without a headrest, which was provided by therapy after the resident experienced a decline and could no longer use his personal electric wheelchair with a headrest. During the transfer, one CNA had to hold the resident's head due to the lack of a headrest, limiting her ability to ensure the resident's extremities were clear of hazards. The wound was later assessed as a large skin tear with bruising and active bleeding, causing pain to the resident. Staff interviews confirmed that the distraction and the need to support the resident's head during the transfer contributed to the incident.