Hospital Administration Case Study

Case Synopsis: A non-ambulatory elderly woman was a patient in a Long Term Care facility. She was being moved from her bed to a chair by a Certified Nursing Assistant (CNA) using a hydraulic lift. The CNA was acting alone. During the transfer, one of the sling leg straps disconnected and the patient fell hitting her head and suffering injuries according to medical records.

Expert Analysis: Analysis of the CNA’s deposition testimony revealed that she did not verify that the leg strap clips were properly connected and she denied that it was her duty to check the connectors since she heard them click into place. Additional, the CNA failed to follow her employer’s policies and procedures that required two persons to move patients using a hydraulic lift. Joint Commission Long Term Care Standards require management to train staff in the proper use of equipment such as the hydraulic lift and to be sure staff follows employer policies, procedures and training.

Result: The CNA inappropriately operated the lift and failed to properly place the sling clips. The Long Term Care Facility failed to train the CNA, as well as failed to follow-up to assure policies and procedures were being properly followed. Additionally, the facility failed to follow Joint Commission Long Term Care Standards. Case settled.