Feb 19, 2019
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Negligent Transfer

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McKnight’s reported on the tragic death of a resident in Minnesota.  The assisted living facility was negligent using a mechanical lift and sling to transfer a vulnerable adult from an electric wheelchair to a bed after the resident sustained a head injury and died two days later. GoldPine Home “failed to adequately train staff, failed to determine the appropriate sling size, and failed to maintain the mechanical lift according to manufacturer’s recommendations,” the Minnesota Department of Health said in a 29-page report issued Dec. 26.

According to the health department report, two unlicensed workers were involved in the Aug. 7 evening transfer of a resident (not identified in the report) who had multiple sclerosis and was taking warfarin, a blood thinner, due to a history of a blood clot. During the transfer, the resident reportedly slipped out of the sling opening, hit his or her head on the leg of the lift and began bleeding from the head.

The resident died in a hospital two days later. “The death certificate indicated that as a consequence of falling from the mechanical lift, s/he died of a traumatic subdural hematoma (burst blood vessel). Contributing factors included warfarin therapy,” the report stated.

During a staff interview, it was determined the preventative maintenance of the mechanical lift had not been performed,” the report said. “There was not a system in place to ensure the appropriate size sling. In addition, staff did not sign off when trained on the mechanical lift policy.”

 

 



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Article Categories:
Abuse and Neglect · Fall Prevention · Staffing

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