Improper Solo Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented a resident’s comprehensive care plan requiring two-person assistance for all mechanical lift transfers. Facility policies on resident assessment and mechanical lifts required an individualized interdisciplinary care plan and specified that at least two CNAs were needed to safely move a resident with a mechanical lift. The resident, admitted in October 2019 with diagnoses including osteoporosis, dementia, and adult failure to thrive, had an ADL care plan and electronic Kardex indicating a need for full mechanical lift transfers with two staff members assisting. Despite this, on the evening in question, CNA #1 transferred the resident alone using a Hoyer lift, contrary to the resident’s care plan and facility policy. During the transfer, CNA #1 lowered the resident onto the bed but left the resident’s shoulders suspended in the sling several inches above the mattress. She then disconnected the right upper sling strap from the lift, causing the resident’s upper body to drop quickly onto the bed and the sling bar to swing into the right side of the resident’s head. The resident immediately began bleeding from the right temple area. When Nurse #1 arrived, the resident was lying on the bed with a deep open wound on the right temple, with blood on the face and in the hair, and the towel used to apply pressure became saturated within minutes. The facility’s unusual event report and hospital emergency department records documented a right lateral temple hematoma and ulceration that could not be sutured, minimally displaced proximal and distal left clavicular fractures, and acute fractures of the left superior and inferior pubic ramus. CNA #1 acknowledged she knew how to access the Kardex, knew the resident required two-person assistance for transfers, and admitted she attempted the transfer without assistance.
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