Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a nurse aide manually transferred a resident who was dependent for transfers and required the use of a full mechanical lift with two staff assistance, as specified in the resident's care plan and physician orders. The nurse aide admitted to physically picking up the resident from bed and placing them into a wheelchair without using the required Hoyer lift or a second staff member. This action was in direct violation of the facility's transfer policy, which mandates the use of mechanical lifts for residents with total dependence to ensure safety and prevent injury. The resident involved had significant medical conditions, including diabetes mellitus, end stage renal disease, and hepatitis C, and was cognitively intact according to assessment. The resident's care plan and orders clearly indicated the need for a mechanical lift and two-person assistance for all transfers. Despite these documented requirements, the nurse aide failed to follow protocol, resulting in the resident experiencing severe pain and swelling in the left stump, which was later diagnosed as an acute comminuted and angulated fracture of the distal left femur. Facility documentation, staff interviews, and clinical records confirmed that the nurse aide did not use the mechanical lift as required and instead performed a manual transfer. This neglectful action directly led to actual harm to the resident, as evidenced by the fracture and subsequent hospitalization. The deficiency was substantiated through witness statements and interviews with facility leadership, who acknowledged the failure to protect the resident from neglect during care.