Resident Injury During Mechanical Lift Transfer Due to Staff Error
Penalty
Summary
A deficiency occurred when a resident who required staff assistance and the use of a mechanical lift for transfers was not safely transferred, resulting in actual harm. The resident, who had generalized weakness, unsteadiness, and was dependent on staff for transfers, was being moved from bed to a recliner by two CNAs using a mechanical (Hoyer) lift. During the transfer, one CNA pressed the wrong button on the lift, causing the resident to be placed in a lying position instead of a sitting position, which led to the resident flipping backward and falling out of the sling. The resident sustained a laceration to the back of the right leg, requiring an emergency room visit and stitches. Medical record review indicated that the resident had intact cognition and a care plan specifying the use of a mechanical lift with two staff for transfers due to a risk of harm or injury related to falls. Witness statements from the CNAs involved revealed that the resident did not have proper arm placement in the sling, and despite this, the transfer was attempted. One CNA, who was inexperienced with the mechanical lift and being trained by the other, followed instructions step-by-step but was unable to prevent the fall when the wrong button was pressed. The incident report and staff interviews confirmed that the resident's improper arm placement and the CNA's error in operating the lift controls directly contributed to the accident. Further interviews with nursing staff and facility leadership revealed that the mechanical lift and sling were functioning properly and were appropriate for the resident. However, there was a lack of communication regarding the exact cause of the incident, as the CNA's admission of pressing the wrong button was not initially reported to supervisory staff. This omission affected the facility's initial assessment of the root cause and the interventions that were implemented immediately following the incident.