Resident Neglect During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident was free from neglect during a mechanical lift transfer. According to facility documentation and staff interviews, a nurse aide attempted to transfer a resident using a mechanical lift (hoyer) without the required assistance of a second staff member. During the transfer, one of the sling loops became loose, causing the resident to slide from the lift and make contact with the floor. The resident sustained a large bruise on the left thigh and reported pain in the left elbow and hip area. The resident was subsequently sent to the hospital for evaluation, where no fractures or dislocations were found. The resident involved had multiple medical conditions, including heart failure, hyperlipidemia, hypothyroidism, lymphedema, a high body mass index, bradycardia, anxiety disorder, and mobility abnormalities. Facility records indicated that the resident had ongoing skin assessments, with documentation of bruising on the lower and upper extremities following the incident. However, some sections of the skin assessment forms, such as the type of skin impairment and body diagram, were left incomplete or lacked detailed descriptions immediately after the event. Interviews with nursing staff and the Director of Nursing confirmed that the nurse aide performed the transfer alone, contrary to facility policy and standard practice, which require two staff members for mechanical lift transfers. The incident was witnessed and reported by staff, and the resident and her family were informed. The facility's policies on abuse, neglect, and skin assessment were reviewed, highlighting the expectation for comprehensive assessments and proper use of equipment, which were not followed in this case.