Neglect During Mechanical Lift Transfer Resulting in Resident Head Injury
Penalty
Summary
The facility failed to protect a resident from neglect during a mechanical lift transfer, resulting in a fall and scalp laceration requiring three staples. Facility policy on abuse, neglect, and misappropriation defined neglect as the failure to provide necessary goods and services to avoid physical harm, and the mechanical lift policy required two staff members for all mechanical lift transfers. The resident involved had non-Alzheimer’s dementia, depression, and muscle weakness, and the care plan and MDS documented that the resident was dependent on staff for transfers and required a full-body lift with assistance of two persons. On the date of the incident, progress notes and hospital records showed that the resident slipped out of the lift pad and onto the floor, was found lying on their back with bleeding from the back of the head, and was transferred to the hospital where a scalp laceration was treated with three staples. Multiple witness statements described that NA E1 had already placed the resident in the air in a whole-body (Hoyer) lift without proper sling attachment and without a second staff member actively assisting. NA E3 entered the room seeking help for another transfer and observed the resident in the lift, leaning forward with upper straps around the neck and shoulders, and noted that not all straps were hooked to the lift, including the absence of the middle hook. Witnesses, including NAs and an RN, consistently reported that facility practice and policy required two staff for mechanical lift transfers and that the sling should have three rings attached. NA E2 reported having previously seen NA E1 coming out of the resident’s room alone with the lift days before the incident and had reminded NA E1 that two people were required for lift use. On the day of the event, NA E3 attempted to assist in moving the resident to the bed, but due to the improper sling application, the resident slid through the lift pad and fell to the floor, striking the back of the head. The DON and RN confirmed that the resident required a mechanical lift with two staff for transfers and that the resident fell from the lift pad during a transfer performed by NA E1, resulting in the scalp laceration.
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