IDPH has cited and fined Sandwich Rehabilitation & Health Care Center after a resident was initially dropped from a mechanical lift and then the facility neglected to ensure the resident was assessed and provided pain management in a timely manner.
The resident in question was being transferred from a shower chair to her bed using a mechanical lift operated by two CNAs. The lift tipped over during the transfer, dropping the resident to the floor and resulting in a right hip fracture.
It was determined that factors contributing to the fall included the lift legs not being fully extended, the wet floor, and the resident’s wheelchair leg pedals obstructing maneuvering of the lift.
The resident complained of pain but initial nursing assessments, pain assessments, and pain management were neglected for approximately 20 hours until the resident was sent to the emergency department the next evening. The Director of Nursing stated “the resident suffered in pain until medication was administered nearly a full day later.”
The resident’s son and power of attorney stated the facility has still not clearly explained to him what happened. He said “It is incompetence at all levels. I continue to worry that she is in constant pain, and they can’t get her back to where she was before they dropped her.” This was the second time the resident sustained a fracture during a transfer at the facility. The resident’s son stated his mother was terrified she would be dropped again.
The Regional Clinical Director confirmed neglect occurred due to failure to notify the physician and family immediately, failure to provide adequate assessments and pain management, and failure to send the resident to the emergency department sooner. The Director stated, “the resident should have been sent to the hospital and had her pain treated. Everyone knew there was a fall, that she had pain and her scheduled Tylenol would not be effective.”
To make matters worse, the state investigation highlights that the CNAs operating the mechanical lift had not received adequate training.
Specifically, the Regional Clinical Director stated she did not have any competencies on file showing that CNAs had received mechanical lift training even though competencies should be completed at time of hire and annually per the facility’s policy.
One CNA did not have any competencies on file while the other CNAs last competency for using the mechanical lift was dated July 25, 2007, indicating she had not received annual training over her more than 20 years working as a CNA.
One CNA confirmed during her interview that she has not received yearly mechanical lift training.
This lack of consistent, comprehensive training for both CNAs and likely other CNAs on proper techniques for operating mechanical lifts appears to be a systemic problem at the facility.
Properly training staff on use of equipment is fundamental to ensuring safe transfers and preventing injuries. The lack of training was very likely a preventable contributing factor that led to the lift tipping over and the resident sustaining a serious hip fracture requiring hospitalization.
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