HospitalInspections.org

32374

Based on record review, and staff interviews, the hospital failed to ensure a patient's right to receive care in a safe setting was upheld during a patient transfer with the use of a mechanical lift, when a patient fell from the lift pad to the floor and sustained a head laceration during a transfer, for 1 of 1 patient reviewed, (Patient ID #1).

Findings are as follows:

Review of a nursing progress note dated 7/18/2025 at 4:00 PM, revealed that Staff A screamed for help because Patient ID #1 had slid off the mechanical lift pad during a transfer from a chair to bed. The patient hit his/her head during the fall and sustained a laceration.

During an interview on 7/22/2025 at 11:40 AM, with Patient ID #1, s/he stated that they had told the staff not to cross the leg straps of the lift pad because it hurts their left leg. S/he said the staff did not cross the straps on the pad, and staff lifted him/her up and s/he slipped out of the pad onto the floor.

During an interview on 7/22/2025 at approximately 3:40 PM, with the certified nurse assistant's (CNA) Staff A, and (CNA) Staff B who were both transferring the patient at the time of the fall. Staff A stated that the patient asked to go back to bed, she asked Staff B to assist her. Patient ID #1 was seated in his/her wheelchair on a lift pad. Staff A stated that when she started to cross the leg straps of the "crisscross pad", the patient said, "don't cross them they hurt my left leg". She stated she did not cross the leg straps. As the patient was raised up in the lift, s/he slid out onto the floor.

During an interview on 7/22/2025 at approximately 3:40 PM with (CNA) Staff B, She stated that the patient just slid right out of the lift pad as s/he was lifted off the chair.

During an interview with the Nurse, Staff D, on 7/22/2025 at approximately 2:30 PM, she stated that hospital should be using the "sling pads" for mechanical lift transfers, and was unaware that the staff were using the "crisscross pads" to transfer patients.

Based on record review, surveyor observation and staff interviews, it has been determined that the hospital failed to provide nursing care in accordance with accepted standards of nursing practice, and hospital policies relative to the transfer of patients via a mechanical lift for 1 of 1 patient reviewed who slid off of the lift pad during a transfer, Patient ID #1.

Findings are as follows:

Review of the hospitals "Safe Patient Handling Procedure" states in part:
"Reassessment:

B: Daily Safe Patient Handling and Movement Considerations:

4. Use mechanical lifting devices and other approved patient handling aids in accordance with instructions and training.

During an interview on 7/22/2025 at approximately 3:40 PM, with the certified nurse assistant (CNA) Staff A, she stated that when preparing the patient for the transfer back to bed, she attempted to cross the leg straps of the "crisscross pad". The patient stated, "don't cross them...". The CNA did not cross the leg straps as required and the patient slid from the lift pad onto the floor.

During an interview with the Nurse Educator, Staff D, on 7/22/2025 at approximately 2:30 PM, she stated that the lift pads have manufacturer labels on them that show a diagram of how to use the pad. She stated that she spoke with Staff A, who acknowledged that she did not follow the instructions for use of the "crisscross pad".