Failure to Follow 3-Person Mechanical Lift Transfer Plan Resulting in Cervical Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan and 24-hour support plan for transfers, resulting in an accident with injury during a mechanical lift transfer. The resident was a paraplegic with bilateral below-the-knee amputations (BKA) who was unable to transfer independently and required either a 3-person manual transfer or a 3-person mechanical lift transfer, as documented in the care plan dated 12/4/2025 and the 24-Hour Support Plan dated 1/13/2026. Despite these documented requirements, only two CNAs participated in the transfer on the date of the incident. According to written statements from the CNAs involved, the resident was dressed, and a sling was placed underneath him and attached to the mechanical lift. One CNA operated the lift to raise the resident from the bed while the other CNA held the chair. During the transfer from the bed to the chair, the bottom right hook/strap of the sling became detached, causing the resident to fall out of the sling onto the floor. One CNA acknowledged that she did not recheck the strap connections after adjusting the height of the mechanical lift and confirmed that only two staff members performed the transfer, even though she knew the resident required three-person assistance. The fall resulted in the resident being sent to the hospital, where an emergency room After Visit Summary documented a closed nondisplaced fracture of the sixth cervical vertebra. The summary noted a linear lucency of the C6 spinous process and included a diagnosis of other closed nondisplaced fracture of the sixth cervical vertebra, initial encounter. Therapy staff reported that they provide functional training and initiate and update 24-hour support plans, and the PT confirmed that this resident required three staff for manual or mechanical lift transfers and that staff had been trained on transfer techniques and positioning. Facility policies on lifting and mechanical lift procedures required at least two staff for mechanical lift use, with a third person to support the head/neck when needed, but the resident’s individualized plan of care specified a three-person assist for all transfers, which was not followed during the incident.
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