Inadequate Protection of Dependent Resident During Mechanical Lift Transfers Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate protection from injury for a non‑ambulatory, cognitively impaired resident who was totally dependent on staff and a mechanical lift for transfers. The resident had dementia with severely impaired cognition (BIMS score of 0), was always incontinent, and was care planned and ordered for Hoyer lift transfers with assist of two staff, and assist with ADLs and toileting at bed level. The resident’s care plan and orders specified non‑ambulatory status, total lift use, and a customized wheelchair with headrest and bilateral leg rests. Prior to the incident, an APRN documented baseline confusion, no pain, movement of all extremities, and bilateral knee contractures, and a skin check shortly before the event showed no new skin impairments. On one day, a nursing assistant reported that during morning care when applying socks, the resident suddenly began screaming, prompting the NA to stop care and notify the night‑shift LPN and the day‑shift LPN. The resident, who had baseline lower extremity edema but no noted discoloration or bruising the prior day, was nonetheless transferred with a Hoyer lift and two‑person assist to a wheelchair and later back to bed, with staff reporting no issues during the transfers and that the resident appeared comfortable after receiving scheduled acetaminophen. The following morning, the charge nurse was notified that the resident had increased generalized body pain, including lower extremity pain, and was uncomfortable during personal care. At that time, the resident’s left leg was noted to be swollen and painful to touch, though the skin was intact, and the resident was observed in the dining room in a wheelchair appearing uncomfortable. Subsequent assessment by an APRN led to orders for a Doppler ultrasound to rule out DVT and an x‑ray of the lower left extremity. Imaging revealed displaced, angulated, recent‑appearing proximal tibial and fibular fractures, and the resident was transferred to the ED, where additional right femur fracture was identified, requiring surgical intervention. The physician and APRNs noted there was no known trauma or recent falls, and one APRN stated that, given the resident’s dependence and lack of reported falls, the injuries were unlikely to have occurred from rolling in bed or an unwitnessed fall, and identified the probable cause of injury as related to use of the Hoyer lift during transfers. The medical director, after reviewing hospital documentation, stated there was no clear etiology but that the injuries could represent osteoporosis‑related fragility fractures potentially associated with mechanical lift transfers.
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