Failure to Follow Two-Person Lift Policy Resulting in Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies for fall reduction and safe use of a portable lifting machine for a resident who required extensive assistance and total dependence for transfers. The facility’s written procedure for the portable lift required two staff for all lift transfers, and the resident’s mobility assessment documented that she was not steady, needed extensive assistance with bed mobility, was totally dependent for transfers, and required two or more persons for transfer support. Despite these requirements, a CNA reported that she routinely transferred residents alone with the portable lift because she did not like to ask for help, and specifically acknowledged transferring this resident by herself on the day of the incident. On the morning in question, video footage showed the CNA wheeling the portable lift into the resident’s room, closing the door, and later slamming it shut, with no other staff entering the room during the initial transfer period. After several minutes, the CNA moved the lift into the doorway and left the room, then returned with two other CNAs, and shortly thereafter the resident was seen being pushed down the hallway in a manual wheelchair with a visible red area on the left cheek. Other staff were observed on video sitting outside the room on their phones and not assisting during the time the CNA was alone with the lift. The DON and Medical Director later stated that the resident’s injuries were consistent with a fall, and the wound nurse stated that it appeared the resident fell or hit her face/body into the lift frame. Following this sequence, multiple nursing notes, ambulance documentation, and hospital records described extensive fresh bruising and trauma to the resident’s face, head, neck, shoulders, chest, arms, hands, and lips, along with pain with movement of the face and neck and difficulty opening the mouth to take medications. The resident was noted to have dried blood on the lip and teeth, a large laceration inside the mouth, hematomas on the forehead and cheek, and bruising in various locations, including patterns consistent with thumb/finger pressure on the right forearm. The DON, wound nurse, and hospital staff all documented the extent and distribution of the bruising, and the resident was transferred to the hospital for evaluation of facial and clavicle trauma and pain with movement of the face and neck. These events occurred in the context of the resident being described as solid in body and weight, requiring multiple staff to transfer her safely when assessed after the incident.
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