Improper Mechanical Lift Transfer Causing Resident Knee Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow its own hydraulic (Hoyer) lift policy requiring two staff members for total body mechanical lift transfers, resulting in an injury to a dependent resident. The facility’s policy, revised on 1/26, states that all nursing staff will be trained on proper use of hydraulic lifts and that staff must obtain assistance from a second staff member. The resident’s MDS documents that the resident is dependent for all transfers and cognitively intact. Nursing progress notes show that in the early morning hours of 11/29, the resident complained of pain above the left knee and was sent to the hospital, where an x‑ray initially showed a sprain of the medial collateral ligament of the left knee and no fracture. The ED nurse later reported that the resident stated hearing a pop when being transferred with a total body mechanical lift, and the resident received multiple pain medications, including Norco, Tylenol, fentanyl, and ketorolac, for pain management. From 11/29 through 12/3, the resident continued to complain of left knee pain and was treated with hydrocodone‑acetaminophen. On 12/3, the NP documented that the resident reported a CNA had hurt her during a prior transfer and insisted that something was wrong with her knee despite a negative x‑ray, requesting further diagnostic testing. The NP noted that an orthopedic referral would be made, and on 12/11 a CT scan of the left knee showed a fracture. On 2/9, the resident reported that a CNA had performed a total body mechanical lift transfer alone, without a second CNA, during which the CNA pushed on her, she heard a pop and a crack, her feet touched the floor, and her left knee hit the side of the bed; the CNA told her to look because she was standing, even though she had not stood in years. That same day, the CNA confirmed performing the mechanical lift transfer without assistance, and the DON and ADON both acknowledged that two staff members are required for all total body mechanical lift transfers, confirming that the transfer was not performed according to facility policy.
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