Failure to Follow Mechanical Lift Policy Results in Resident Fall
Penalty
Summary
A deficiency occurred when a staff member failed to follow facility policy regarding the use of a mechanical lift for resident transfers. The facility's policy required at least two staff members to operate a Hoyer lift for transfers, but a certified nursing aide (CNA) attempted to transfer a resident alone. During the transfer, the CNA noticed a wheel on the lift was stuck and that the resident's arm was out of the sling. While attempting to reposition the resident and equipment, the resident fell to the floor, landing on her buttocks. The incident was witnessed by other staff who responded to the noise and found the resident on the floor, still attached to the lift sling, with the wheelchair adjacent to her. The resident involved had a history of cerebrovascular disease, muscle weakness, restless legs syndrome, edema, and impaired coordination. She was cognitively intact and dependent on staff for all transfers, as documented in her care plan and Minimum Data Set (MDS). Her care plan specifically identified her as being at risk for falls and required the use of a full-body mechanical lift with sufficient staff for transfers. At the time of the incident, the CNA reported that no other aides were available to assist, despite multiple staff being present on the unit. The CNA had completed annual competency training on lift use prior to the incident. Following the fall, the resident was assessed by nursing staff and reported mild soreness but no significant injuries. Interviews with staff confirmed that only one aide was present during the transfer, in violation of facility policy. The nurse on duty was informed of the policy violation but did not immediately remove the CNA from duty. The incident was later reported to facility administration, and further investigation revealed that the policy was not followed during the transfer, directly leading to the resident's fall.