F0689

D

Failure to Use Required Mechanical Lift Resulting in Resident Leg Laceration

Bowling Green, Kentucky Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident received adequate supervision and required assistive devices to prevent accidents during transfers. Facility policy on Accidents and Supervision required that residents’ environments remain as free of accident hazards as possible and that each resident receive adequate supervision and assistive devices, including implementation and monitoring of specific interventions to reduce risk. The Interim Executive Director stated the facility did not have a policy on the use of mechanical lifts. The resident at issue, R37, had diagnoses including unspecified dementia, scoliosis, and overactive bladder, and was assessed with a BIMS score of 11/15, indicating moderate cognitive impairment. The resident was dependent for chair/bed-to-chair transfers and used a wheelchair.

R37’s comprehensive care plan, initiated shortly after admission, identified a self-care deficit and risk for decline related to impaired mobility, with interventions including assistance with ADLs and assistance of two staff. On 02/25/2025, the care plan was updated to specify that the resident required a total lift with a green sling and assistance of two staff for transfers, and the Comprehensive Device Assessment documented the use of a wheelchair, total lift with green sling, and side rails for positioning, including use of the green sling for tub transfers. The current assignment sheet also indicated that the resident required a lift with two-person assist and a green sling. Staff interviews confirmed that assignment sheets listed the level of assistance and sling color for residents who used lifts, and that R37 was known to require a total lift for transfers.

Despite these assessments and care plan directives, on 04/09/2025 CNA10 transferred R37 from wheelchair to bed alone and without using the required mechanical lift. During this transfer, the resident sustained a vertical, full-thickness laceration to the right lower leg, which RN5 observed to have been caused by the iron bed frame. The injury required control of bleeding, physician notification, and transfer to the hospital emergency department, where the diagnosis was a leg laceration requiring sutures and wound care instructions. R37 later stated that staff usually used a mechanical lift to get her out of bed and that she remembered getting a big cut on her leg when an aide tried to move her without the lift. The facility’s internal investigation concluded that, despite recent documented training on use of the mechanical lift, CNA10 did not follow the care plan and did not use the mechanical lift as required, resulting in the resident’s leg laceration.