FORT WORTH, TX – THE HARRISON AT HERITAGE

Based on interview and record review, the facility failed to ensure each resident received adequate assistance devices to prevent accidents for one (Resident #1) of four residents reviewed who required staff assistance with transfers. CNAs A and B failed to transfer Resident #1, who was care planned to be transferred utilizing a mechanical lift, with a mechanical lift which resulted in the resident being injured and sustaining a fracture to his right hip. This failure placed residents at risk for falls, lacerations, fractures and the need for hospitalization .

Interview on [DATE] at 2:58 PM with CNA B revealed she thought Resident #1 required a mechanical lift transfer. She stated CNA A told her the resident was able to use the sit to stand lift. CNA B stated she wanted to use the mechanical lift. She stated on the day of the incident CNA A and she transferred Resident #1 from his w/c to the shower chair. She stated they used the sit to stand lift with no issues. She stated after his shower they were going to transfer him into bed. They got him hooked into the sit to stand lift and when CNA A started to lift the resident he was fine and then he let go of both bars. She stated he was on his knees and they lowered him to the floor. CNA B stated the resident had not complained of pain. She stated LVN C was notified and she assessed the resident. She stated they used a mechanical lift to get him into bed. CNA B stated LVN C did not know they were using the sit to stand lift to transfer the resident. CNA B stated at the time she did not know where to find a resident’s ADL care info. She stated she worked at the NF (nursing facility) for two years and that was the first time she had transferred Resident #1. She stated she was terminated from the facility.