Failure to Manage Bed Bolster Hazard During Mechanical Lift Transfer
Penalty
Summary
The deficiency involves the facility’s failure to identify and prevent an avoidable accident hazard related to the combined use of bed bolsters and mechanical lift transfers for a resident. The resident had Alzheimer’s dementia, anxiety disorder, osteoarthritis, moderately impaired cognition, was dependent on staff for grooming, bed mobility, and transfers, and was assessed as being at risk for falls. The resident’s fall care plan specified that the left side of the bed was to be placed against the wall to prevent falls or rolls out of bed, but there were no care plan interventions addressing the use of a bed bolster. The facility also lacked a physician order, assessment, care plan entry, or representative consent for the bolster that had reportedly been in use on the resident’s bed for a couple of years. On the day of the incident, staff used a mechanical lift to transfer the resident from bed to wheelchair while a wedge-shaped bolster remained along the right side of the bed, with the bed at working height. Nursing assistants involved in the transfer reported that the sling was already hooked to the lift and that, during the lift, the lower left sling loop came off the lift hook as the resident was moved over the side of the bed. Staff later acknowledged that the bolster wedge should have been removed or taken down before performing the mechanical lift transfer and that if the bolster is not moved, the sling can get caught on it. One NA stated they had not been told to remove bolsters for mechanical lifts, and another stated that looking back, the bed had been too high and the bolster should have been removed. As a result of the sling loop disconnecting from the lift hook, the resident slid out of the sling and fell to the floor, landing partially on the mechanical lift leg. The resident sustained a forehead laceration, bruising to the left arm and elbow, skin shearing, bruising, and swelling to the left ankle, and was transported to the hospital. The resident was diagnosed with a left ankle fracture, treated with a leg splint, and had a shallow scalp laceration. Upon return, the resident was observed yelling out and later groaning in pain, with visible bruising on the forehead. The DON, restorative nurse, and administrator acknowledged there were no written policies, documented training, or guidelines specific to mechanical lift transfers in conjunction with bed bolsters, and the administrator stated they were not aware that bolsters could be a hazard.
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