Failure to Safely Operate Mobility Van Lift Leads to Resident Fall and Increased Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe transfer for a resident who required use of a mobility van mechanical lift, resulting in a fall from the van lift platform to the ground. The resident had moderately impaired cognition, required staff assistance with dressing, personal hygiene, and transfers, and used a manual wheelchair but was independent with mobility. Diagnoses included heart failure, arthritis, aphasia, hemiplegia, and seizure disorder. Prior to the incident, the resident’s pain assessments and MAR entries showed low pain levels managed with scheduled acetaminophen, and the resident denied having pain despite receiving scheduled pain medication. On the day of the incident, the facility van driver lowered the wheelchair lift platform fully to the ground to ensure it was on level ground, but then forgot to raise the platform back up to the van and did not attach the safety belt before attempting to unload the resident. The driver entered the van and pushed the resident’s wheelchair backward, not realizing the lift platform was not in position, causing the resident and wheelchair to fall backward off the edge to the ground. The resident sustained a laceration to the back of the head, a large hematoma and jagged skin tear to the right hand/wrist, and complained of back pain. Hospital evaluation identified wedging of several vertebrae of uncertain age, demineralized bones limiting detection of acute fractures, and musculoskeletal back pain, with concern that vertebral compression fractures might be chronic but also possibly exacerbated by the recent injury. Following the fall, documentation and interviews indicated the resident experienced a significant change in condition. The resident returned from the hospital with lower back pain, was not alert or oriented per baseline, and complained of pain with transfers and rolling in bed. Therapy and nursing notes documented poor transfers, increased confusion, and pain requiring use of a full-body lift and increased assistance with ADLs, including bed mobility, transfers, dressing, and locomotion. Pain ratings increased substantially, with frequent reports of severe pain interfering with therapy and daily activities, and the resident required multiple narcotic pain medications, including fentanyl patches, hydrocodone-acetaminophen, and oxycodone, with associated somnolence and lethargy. Staff and family interviews described the resident as more confused, very sleepy with pain medications, not eating well, not participating in activities as before, and having ongoing significant pain and functional decline after the fall. The events leading to the deficiency were further linked to systemic issues in staff training and facility procedures related to the mobility van and wheelchair lift. The facility safety officer reported that he provided initial training to staff on the van and lift when they were newly hired or began using the van, but there were no yearly refresher trainings, no formal competencies, and no documentation or proof of training or competency for authorized van drivers and lift operators. He also stated there was no policy or lift manual for the vehicle, and that instructions were limited to those posted on the van doors. The van driver involved in the incident stated he had been driving the van for approximately four years, had initial training when he started, and had been working many extra shifts, feeling overworked, stressed, and distracted at the time of the incident. Another authorized driver confirmed that she had only received initial training and a quick rundown when a new van was obtained, without formal wheelchair lift training or annual competency. The administrator acknowledged that the root cause analysis after the fall identified the lack of annual training and the absence of a policy on the van’s wheelchair lift as contributing factors.
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