Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate assistance and supervision with assistive devices during transfers for a resident identified as being at risk for falls and totally dependent for transfers. Facility policy on comprehensive person-centered care plans required the interdisciplinary team to develop and implement care plans with measurable objectives and interventions based on comprehensive assessments, and the accident/incident policy required investigation and analysis of resident vulnerabilities. For this resident, the admission MDS documented cognitive intactness and total dependence for transfers, requiring assistance of staff for all transfers between bed and chair. A physical therapist’s assessment documented abnormalities of gait and mobility, a history of recurrent falls, and that the resident was at risk for falls and required a mechanical lift (Hoyer lift) for all transfers. The therapist noted that nursing was notified of the resident’s total dependence transfer status, and subsequent therapy documentation continued to identify total dependence with use of a mechanical lift. Physician and physiatrist notes described the resident as cognitively intact, alert, oriented, and able to follow commands. The comprehensive care plan identified the resident as at risk for accident hazards due to reduced balance, strength, and activity tolerance, with reduced ability to perform functional mobility and ADLs, and specifically directed use of a mechanical lift for all transfers, with nursing staff educated on this intervention to prevent falls. On the day of the incident, the resident was seated in a wheelchair and activated the call light requesting to return to bed. A nursing assistant (Employee E5) responded, reported the resident wanted to go back to bed, and placed a walker in front of the resident. While assisting the resident to stand from the wheelchair in preparation for a transfer to bed, and doing so alone without use of the mechanical lift or assistance of a second staff member, the resident fell to the floor. The nursing assistant later stated they were unaware the resident required a mechanical lift and two-person assistance for transfers. Blood was observed on the floor near the resident after the fall. The resident was sent to the emergency room and diagnosed with a comminuted distal fibular shaft fracture, a transverse fracture of the medial malleolus, and dislocation of the tibiotalar joint of the right leg, requiring surgical repair. The therapy director confirmed that the care plan required a mechanical lift for transfers and that nursing staff failed to implement this intervention.
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