Failure to Honor Resident Choice Due to Unresolved Lift Equipment Issues
Penalty
Summary
The facility failed to promote and facilitate resident self-determination and resident choice regarding when to get out of bed for one cognitively intact resident who was dependent on staff and mechanical lifts for transfers. The resident, admitted with multiple diagnoses including unspecified atrial flutter, type 2 diabetes mellitus, morbid obesity, hypertensive heart disease, vascular dementia, and an above-the-knee left leg amputation, had a care plan indicating an ADL self-care performance deficit requiring use of a lift system with a brown sling and assistance of two staff for transfers. Despite this, over a specified weekend the resident reported being left in bed after repeatedly asking to get up and being told there were no lift pads available or that the lift was not working. Multiple staff interviews confirmed that lifts on the resident’s hall were reportedly not working during that weekend, and that residents requiring lifts, including this resident, were not gotten out of bed due to lift issues and problems with keeping batteries charged. One CNA stated she attempted to obtain a lift from other halls but found those lifts also not working, and another CNA reported that at times only one lift in the building was working and that the resident typically did not get out of bed when lift problems occurred. An LPN acknowledged knowing the resident did not get out of bed that weekend and heard the resident state he expected to get up on Monday. The resident’s responsible party reported receiving calls from the resident over the preceding weeks about difficulty getting out of bed due to lift problems and was later informed by administration that there had been lift issues. The administrator stated he had been aware of lift issues earlier in the week and had maintenance check all lifts, batteries, and charging ports, but he was not informed of lift problems on the specific weekend in question, and confirmed that if the resident had requested to get out of bed, staff should have used a working lift.
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