Failure to Safely Perform and Care Plan Mechanical Lift Transfer and Notify Representative After Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall, to accurately and timely care plan for mechanical lift transfers, to ensure two staff were present during a mechanical lift transfer, and to notify the resident’s representative of a fall. The resident had diagnoses including osteoporosis, Alzheimer’s disease, dementia, dysphagia, a displaced fracture of the left femur, and a history of falling, and was documented as severely cognitively impaired and dependent on staff for bed-to-chair transfers. The care plan identified the resident as at risk for falls and self-care deficits, with interventions to follow the facility fall protocol and anticipate and meet needs, and noted that assistance with transfers might occasionally increase due to fluctuating needs. However, the care plan did not include a specific focus on mechanical lift transfers until several days after the incident, despite multiple staff interviews indicating the resident had required mechanical lift assistance for more than a year. On the date of the incident, a CNA with a little over a month of employment at the facility attempted to transfer the resident from bed to chair using a mechanical device without assistance from a second staff member. During the transfer, when the resident’s legs lifted off the bed, the resident began to slide. The CNA realized the device being used was a weight machine rather than the appropriate mechanical lift for resident transfers. The CNA reported that the resident “kind of slid down slow,” and the CNA paused the transfer and called for help. The DON and ADON, who were rounding on the unit, heard the call for help and entered the room, observing the resident in a sling off the bed and the CNA attempting the transfer alone. Both the DON and ADON stated the resident’s lower body did not look secure or comfortable, and they, along with the CNA, lowered the resident to the floor. The facility’s own policies required two caregivers for mechanical lift transfers and directed that the resident’s responsible party be notified of incidents, accidents, and falls. The CNA had signed the Resident Handling Policy and completed a mechanical lift competency validation that specified use of a second caregiver. Despite this, the transfer was performed by a single CNA, and the incident was documented by the DON as an “other incident” rather than a fall. The DON stated the facility was calling the event an “assisted transfer” to the floor and not a fall, and both the DON and ADON acknowledged they did not inform the resident’s responsible party at the time of the incident. The responsible party was not notified about staff placing the resident on the floor until several days later, and the facility’s conclusion was that the event was not a fall, despite regulatory guidance defining a fall as unintentionally coming to rest on the floor or a lower level, including episodes where a resident would have fallen if not assisted to the floor.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.