IDPH has cited and fined Allure of Pinecrest nursing home in Mount Morris after a resident suffered a torn rotator cuff and long-term impairment of her arm when a CNA improperly transferred the resident with a sit-to-stand mechanical lift.
A sit-to-stand lift is a type of lift commonly used in nursing homes. This type of lift should be used only with residents who have some ability to bear weight and who are cognitively intact enough to follow instructions from staff. As with Hoyer lifts, this lift requires the assistance of two staff members to use it safely – one to operate the controls of the lift, the other to assure the safety of the resident.
The resident in question was a 95-year-old woman with multiple complex medical conditions that caused general frailty and dependency on staff for assistance with mobility and transfers. Her care plan indicated she needed extensive hands-on help from staff to transfer positions. A sit-to-stand mechanical lift was ordered by her doctor to facilitate safe movement given her instability.
On the day of the incident the resident was being transferred from her wheelchair to the bathroom toilet using a sit-to-stand mechanical lift.
The initial CNA performing the transfer by herself had difficulty operating the equipment smoothly. When the resident started to sink down in the sling, indicating improper positioning, the CNA raised the lift higher to compensate.
The resident yelled out that this was hurting her left arm. But the CNA ignored her cries and continued maneuvering the lift up and down instead of stopping to adjust the resident’s position.
The CNA then called over an assist who took over while the initial CNA briefly left. At that point the resident declared “Thank God you’re here, she was making my shoulders hurt.”
Upon returning and resuming operation of the lift, the CNA continued having problems with keeping the resident secured. Finally the assisting CNA took over fully and completed the transfer.
After moving the resident to her bed, this CNA noticed a skin tear on her left arm that had not been there previously. The resident was ultimately diagnosed with a complete rotator cuff tear.
A different CNA reported that post-injury, the resident said the aide “almost hung me” and must not have known how to use the lift.
Facility policy dictates two staff members must operate mechanical lifts. The resident’s physician agreed having two would be advisable for such a weak resident.
In this case the facility failed to ensure the resident’s safe handling during the transfer which led to long-term impairment of her arm. This causes undue suffering for an elderly woman in declining health.
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