Improper Mechanical Lift Use Leads to Resident Fall and Minor Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of a full body mechanical lift during a bed-to-chair transfer, resulting in a fall with injury for one resident. The resident had no cognitive impairment, required substantial/maximal assistance for transfers, and had diagnoses including heart failure, diabetes, and a left heel pressure ulcer. The resident was care planned as a fall risk, with directions for staff to use a full body lift with two staff for transfers to a shower chair. On the day of the incident, two CNAs used a brand-name full body mechanical lift to transfer the resident from bed to a shower chair. During the transfer, staff reported that after raising the resident in the sling, the CNA operating the lift pressed the control to separate the lift’s legs and heard the usual grinding noise, then assumed the legs had fully opened. She then backed the lift away from the bed and began to turn it toward the shower chair. As the lift was turned, it began to lean to one side, and the wheels lifted from the floor. Staff accounts and subsequent checks indicated that the legs of the lift had not been fully opened, causing imbalance and tipping of the lift while the resident was suspended. As the lift tipped, one CNA attempted to hold the lift and another attempted to support and lower the resident. The lift’s crossbar struck the resident’s eyebrow, causing a bruise measuring 2.5 cm by 1 cm, and the resident also sustained a skin tear on the lateral side of the right great toe measuring 1 cm by 0.5 cm. The resident was found on the floor on her back with knees bent, still attached to the lift, which was on its side. The resident reported that the machine tipped over while staff were transferring her. Staff and nursing assessments documented the bruise to the forehead and the skin tear to the toe, which healed within a few days, and the resident denied pain, headache, or nausea following the incident.
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