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Based on review of facility policy, review of manufacturer's recommendations, medical record review, and interviews, the facility's failure to correctly use a patient lift during a transfer resulted in a fall with injury for 1 patient (Patient #1) of 5 patients reviewed for transfers.

The findings included:

On 2/28/2021 at approximately 5:45 PM Certified Nursing Assistant (CNA) #1 and Registered Nurse (RN) #1 were transferring Patient #1 from the bedside chair back to bed using a mechanical lift. During the transfer process CNA #1 and RN #1 failed to expand the base of the lift, per hospital policy and manufacturer's direction for use, resulting in the lift turning over and Patient #1 dropping to the floor hitting his head.

Refer to A-0398 for additional findings.

Based on review of facility policy, review of the Certified Nursing Assistant job description, review of manufacturer's recommendations, medical record review, and interviews, the facility failed to ensure staff properly used a patient lift during a patient transfer, resulting in a fall with injury for 1 (Patient #1) of 5 patients reviewed for transfers.

The findings included:

Review of the facility policy titled "Safe Patient Handling Program and Equipment," last revised 10/2019, showed "...all nursing personnel on inpatient nursing units, Physical Therapy, and Occupational Therapy, will receive education on proper assessment criteria for patients that may benefit from the use of lift equipment...it is the responsibility of employees to take reasonable care of their own health and safety, as well as that of their co-workers and patients during patient handling activities by following this policy. Non-compliance will indicate a need for retraining..."

Review of the Certified Nurse Assistant (CNA) job description, last reviewed 2/5/2019, showed "...functions as a direct patient caregiver performing task to assist Registered Nurses. Performs hands-on care, assistance with ADL's [activities of daily living] and specified technical tasks for a group of patients under the supervision of the Team Leader..."

Review of the lift manufacturer's recommendations, not dated, showed "...Lifting from bed to chair...if the base is in the narrow position, adjust it to the widest position once you are clear from the bed and always before turning..."

Medical record review showed Patient #1 was admitted to the facility on 2/18/2021 with diagnoses including Acute Renal Failure, Left Leg Cellulitis, Coronary Artery Disease, and Hypertension. The patient had significant swelling and redness in his left lower extremity. The patient's weight was 339 pounds.

Medical record review of a Falls Risk Assessment for Patient #1 dated 2/18/2021 at 2:24 PM showed the patient scored a 55 on the assessment indicating the patient was at a high risk for falls and fall preventions were put in place for the patient.

Medical record review of a Nurses Note dated 2/28/2021 at 5:50 PM showed "...at approximately 5:45 PM pt. [patient] requested to go back to bed...sitting in chair...CNA and RN [Registered Nurse] used [named] lift to move patient back to the bed. While moving the patient closer to the bed, the lift flipped causing the patient to fall. He received a hit to the back of his head, his back, and hips. VS [vital signs] stable. Neuro [neurology] assessment performed pt. alert and oriented. [named hospitalist] was notified. Scans were ordered..."

Medical record review of a Hospitalist's Progress Note for Patient #1 dated 2/28/2021 at 7:16 PM showed "...was called with patient having a fall today while being transferred with a lift machine. He reportedly had about a 3 ft [foot] fall...hitting his head and landing flat on his back. There is no loss of consciousness. He did have a small bump on the top of this head that was bleeding and had some bruising around his right cheek. He is awake and alert and oriented x [times] 3. He reports some back pain but that is more generalized...Does have mild pain in the top of his head...is not tender on any of his lower extremity joints or upper extremity joints. C-Spine [cervical spine] nontender to palpation. Will check CT [computed tomography] scan of the brain...C-Spine. Will check x-rays of the lumbar and thoracic spine as well as the hips to rule out a fracture. Will follow neuro checks q [every] 4 [hours]..."

Medical record review of a Discharge Summary dated 3/1/2020 at 11:50 AM showed the patient had no fractures or head bleed. The patient was transferred to a skilled nursing facility on 3/1/2021.

During an interview on 3/15/2021 at 1:10 PM, the Nurse Manager confirmed staff were transferring Patient #1 from a chair to his bed using a mechanical lift, but the lift was not widened enough (base of the lift was not expanded enough, per the manufacturer's instructions) to support the patient and the locks were not secured. When the lift was turned to position the patient over the bed, the lift tipped over causing the patient to be dropped approximately 3 feet to the floor. The Nurse Manager stated the facility had implemented training for CNAs (on 3/10/2021, prior to the survey) regarding the correct use of the lift, but the training had not been provided to the Registered Nurses.

During an interview on 3/15/2021 at 1:30 PM, RN #1 stated "...when we started to lift the patient the base was not widened [base of the lift was not expanded enough, per the manufacturer's instructions] to hold the patient and I don't think the locks were secured...we were going to pivot the lift to the bed...all of the sudden the lift flipped and the patient landed in the floor on his back and hit his head on the floor. He did have a small laceration to his head..." She stated she had not received any additional training regarding the use of the lift after the incident on 2/28/2021.

During an interview on 3/15/2021 at 3:30 PM, CNA #1 stated the patient had requested to go back to bed and he could not stand up by himself. The CNA stated "...when we lifted the patient up and attempted to turn him to the bed, the lift tilted and flipped...the patient landed in the floor on his back. The base of the lift was not widened to support the patient's dead weight..."

During an interview on 3/15/2021 at 3:50 PM, the Director of Medical/Surgical Unit, confirmed the facility had not re-educated the licensed Registered Nurses on the correct use of the mechanical lift since the incident with Patient #1 on 2/28/2021.

Summary of facility actions taken after the incident:
1. CNAs were scheduled to work with the Physical Therapy Assistant for a 4-hour period. The CNAs were instructed on patient care involving bed mobility, transfers to bed and chair, use of a gait belt and walker, management of patient equipment and room set up, fall prevention, reducing falls, and weight bearing/hip precautions. The CNAs were also instructed on safe and proper use of the mechanical lift during transfers of patients. The training included hands on training with direct observations.
2. The CNAs with re-evaluated 2 weeks after their initial training to ensure compliance with use of the lift.
3. The training was started on 3/10/2021 and will be ongoing until all CNAs have received the training. The facility had not implemented training for the RN's related to the patient lift.
4. Safe patient handling focused on sling lift equipment will be demonstrated/discussed during the next staff meeting on 4/7/2021.
5. The facility will provide re-education with all unit staff concerning lift equipment and safe patient handling within 90 days.