Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a facility failed to provide adequate supervision and implement effective transfer interventions as ordered by a physician, resulting in a preventable accident and actual harm to a resident. The facility's policy required the use of mechanical lifts for residents who are totally dependent or require extensive assistance for transfers, and specifically prohibited manual lifting to minimize risk of injury. Despite these protocols, a nurse aide physically picked up a resident from bed and placed them into a wheelchair without using the required mechanical lift or a second staff member, as mandated by the resident's care plan and physician orders. The resident involved had significant medical conditions, including diabetes mellitus, end stage renal disease, and hepatitis C, and was assessed as being dependent for transfers, requiring a full mechanical lift with two staff members. The resident was cognitively intact according to the BIMS assessment. Following the improper manual transfer, the resident experienced severe pain and was subsequently diagnosed with an acute comminuted, impacted, and angulated fracture of the distal left femur. Staff interviews and facility documentation confirmed that the nurse aide did not follow the prescribed transfer method, and the resident's care plan and orders were accurate at the time of the incident. The failure to use the mechanical lift as ordered directly resulted in the resident sustaining a serious injury during the transfer process.