Failure to Assess and Safely Manage Use of Power Lift Chair Resulting in Fall With Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement its standards of practice for assessing and safely using a power lift chair for a resident with severe cognitive and physical impairments. The resident was admitted after a recent left PCA stroke with right-sided hemiparesis, expressive and receptive aphasia, severely impaired cognition, disorganized thinking, impaired vision, and dependence on staff for all ADLs and transfers. On admission, therapy evaluations and the care plan identified that the resident could not bear weight on the right lower extremity, had right knee buckling, poor trunk control, leaned to the right, and required a Hoyer lift with assistance of two for transfers. The Morse Fall Scale score placed the resident at high risk for falls, and the care plan directed staff to follow therapy recommendations, including use of a Hoyer lift for transfers. After admission, the resident’s family brought in an electric lift recliner that the resident had never used before and was not familiar with. The family did not explicitly notify administrative staff, but facility staff observed the chair being delivered and began using it for the resident within a day or two of admission. Multiple NAs and RNs reported transferring the resident into the lift chair using a Hoyer lift on several occasions over the following days. Staff interviews revealed that no lift chair assessment was completed by nursing or therapy prior to the resident’s use of the chair, despite an existing facility policy requiring evaluation of a resident’s ability to safely operate an electric recliner by therapy or an RN. Several staff members acknowledged they were aware that a lift chair assessment should have been completed before use, but they either assumed the chair was safe because it was in the room or did not verify whether an assessment existed. Therapy staff, including the PTA and PT, observed the resident seated in the lift chair during therapy sessions and used the remote themselves to adjust the chair, but no formal lift chair assessment was initiated. Interviews with the DON, care coordinator RN, MDS coordinator, therapy staff, and NAs consistently described the resident as confused, forgetful, unable to stand or walk, with right-sided paralysis and poor safety awareness, and indicated that the resident would not have been safe to use the lift chair or its remote independently. On the day of the incident, NAs transferred the resident via Hoyer lift from bed to the lift chair, elevated the feet with the remote, reclined the chair, covered the resident with a blanket, and placed the remote either over the left armrest or in the side pocket, in a manner that still allowed the resident potential access to the cord or remote. Shortly thereafter, the resident was found on the floor on her right side between the bed and the lift chair, with the chair in the fully upright stand position and the right foot in eversion with obvious ankle deformity. The resident was unable to provide a clear account of what happened. ER evaluation and x-rays confirmed a new trimalleolar fracture of the right ankle with lateral subluxation of the talus, which staff and providers attributed to the unwitnessed fall from the lift chair in the context of the resident’s inability to safely use or tolerate the lift mechanism.
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