Failure to Use Two-Person Assist With Mechanical Lift Resulting in Humerus Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from accident hazards and received adequate supervision during a mechanical lift transfer. Facility policy on "Resident Transfers To/From and Within Equipment" required staff to use appropriate safety techniques and to follow the resident’s individualized transfer status as documented in the care plan and nursing assistant documentation. For this resident, the Resident Care Guide directed that transfers be completed using a Sara (sit-to-stand) lift with two-person assist, and the care plan specified use of a Maxi lift with assistance from two staff. The resident’s MDS assessments documented the need for maximal assistance and two-person support for transfers, and the facility’s NHA confirmed that the facility requires two-person assist with all mechanical lifts. The resident had diagnoses including osteoporosis and a displaced fracture of the surgical neck of the right humerus, and later a significant change MDS reflected severely impaired cognition and a change in functional ability requiring a Maxi lift for transfers. On the evening of the incident, the resident was observed at dinner and afterward in her wheelchair using her right arm normally and coloring, with no complaints of pain. Around the time of the event, an LPN was in another resident’s room with a nursing assistant (Employee 3) setting up a shower, and later returned to the office when another nursing assistant (Employee 1) requested that she assess the resident’s arm. When the LPN entered the room, the resident was already in bed, changed into a gown, visibly upset, crying, and in pain, with a hard, swollen right arm that was painful with movement. The resident was unable to explain what had happened but repeatedly referred to "he" and asked the LPN not to leave her. Employee 1 initially told facility administration that a second staff member (Employee 3) had assisted with the stand-up lift transfer, but subsequent investigation and a written statement from Employee 3 confirmed that Employee 3 did not assist with putting the resident to bed. In a written statement, Employee 1 reported transferring the resident into bed with the sit-to-stand lift and then noticing the right arm swelling while the resident was still in a sitting position in bed, at which point the nurse was alerted. An incident report documented that the resident’s right arm appeared swollen, she was crying and expressing pain, and she was unable to explain what may have happened. An x-ray obtained that evening showed an acute mid-shaft fracture of the right humerus with moderate angulation and displacement and mild soft tissue swelling, without dislocation. Subsequent observation showed the resident’s right hand to be non-functional, with curled fingers and wrist and inability to move the right hand, while the left arm and hand remained functional. The DON and NHA confirmed that Employee 1 was the only person who provided evening care and transferred the resident from wheelchair to bed during the shift in question, and agreed that Employee 1 should have followed the care plan and had a second person present for the lift transfer.
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