Improper Mechanical Lift Transfer Leading to Resident Fall and Brain Bleed
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively impaired, fully dependent resident was safely transferred using a mechanical lift, resulting in a fall with major injury. The resident had Alzheimer’s disease, dementia, a history of falling, abnormal posture, poor vision, and overall debility, and was care planned and ordered for mechanical lift use for all transfers. The resident’s ADL and fall care plans identified impaired ability to perform ADLs, high fall risk, confusion, impaired safety awareness, impaired mobility, and poor vision, with interventions including use of a mechanical lift for all transfers and maintaining a safe environment. Despite these identified needs and interventions, the resident experienced a fall during a staff-assisted mechanical lift transfer. On the date of the incident, two CNAs were transferring the resident from a chair to bed using a mechanical lift. Witness statements from both CNAs indicated that during the transfer, one of the sling’s bottom loops/straps was not properly secured to the hook/clip on the lift. One CNA reported that as they lifted the resident into the air and moved to remove the chair from underneath, she noticed the loop had come off the hook, and before staff could react, the resident fell forward to the floor. The other CNA similarly stated that as the resident was lifted, the strap came unclipped and the resident went forward onto the floor. The facility’s investigation of the self-reported incident documented that the left bottom loop of the sling came out of the hook on the lift during the transfer, causing the resident to fall and strike her head. Following the fall, the resident was found lying on her back on the floor with her legs and left upper body over the bottom of the lift device, with visible bleeding from an open area on the left side of the forehead and a lump approximately five centimeters in circumference. The resident also had deep purple discoloration to the right second finger and displayed non-verbal indicators of pain, such as facial grimacing, but was unable to verbalize pain due to severe cognitive impairment and being rarely or never understood. The nurse’s incident documentation and nurse’s note replicated the description of the resident’s position and injuries but did not state that the resident had fallen from a mechanical lift during a transfer. The resident was sent to the emergency department, where hospital records documented that she had fallen from a mechanical lift that was at its highest setting at the time of the fall, and a CT scan revealed a subarachnoid hemorrhage (brain bleed). Facility leadership, including the Administrator and DON, later acknowledged in interviews that the fall was due to human error, specifically that staff did not ensure the sling loop was properly secured before initiating the lift, and that the incident occurred during a mechanical lift transfer. The facility’s written policies for Invacare lift use required two staff to operate the lift, mandated that slings be hooked to the lift with hooks facing outward/away from the resident, and assigned responsibility to nursing aides to monitor slings for rips, holes, fraying, or other concerns with every use. The fall prevention policy required completion of an incident report by the nurse, timely notification of the physician and family, discussion of the incident in morning report, and implementation of interventions as indicated, including referral for staff education or discipline if employee work performance was implicated. In this incident, although two staff were present, the sling loop was not properly secured to the lift hook before the resident was raised, and the incident report and nurse’s note did not document that the fall occurred from a mechanical lift during a transfer, despite this being reported in witness statements, hospital documentation, and the facility’s own SRI investigation.
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