Inadequate Supervision During Mechanical Lift Transfer Leads to Resident Fall and Nasal Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and safe use of a mechanical lift during a transfer, resulting in a resident fall with injury. The facility’s mechanical lift policy requires staff to position residents comfortably and safely in the sling and chair, including grasping the top of the sling and, if needed, gently pushing on the resident’s knees while lowering them. The resident involved had an anxiety disorder, a cognitive communication deficit, and severe cognitive impairment, with a care plan addressing communication deficits through allowing extra time, repeating information, not rushing, using one-step directions, and other supportive strategies. The resident’s care plan also documented an actual fall during a mechanical lift transfer to a wheelchair, during which the resident rolled out of the sling onto the floor and was later diagnosed with fractures of both nasal bones, the nasal septum, and a nasal laceration. On the day of the fall, two CNAs conducted the mechanical lift transfer using a sling described by one CNA as a type the resident disliked because its fuzzy material made it easier to slide. Multiple CNAs, including those involved in the incident and others familiar with the resident, reported that the resident frequently leans forward in the sling and requires repeated reminders to sit back. During the incident, one CNA operated the lift controls while the other stood behind the resident, attempting to guide her by holding the sling straps as the resident repeatedly leaned forward. Despite the resident’s continued forward leaning, the CNAs proceeded with lowering her, and she fell forward out of the sling, landing face-first on the leg/foot of the mechanical lift. Staff interviews, including from the CNA supervisor, indicated that CNAs are trained not to rush transfers and not to continue a transfer if a resident is leaning forward or moving unsafely, and that in this case the transfer should not have continued until the resident was in a safe position.
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