Cna incident investigation

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sallyrnrrt, ADN, RN

Specializes in critical care, ER,ICU, CVSURG, CCU. 2,395 Posts

I know it was so careless and foolish, the aid was changing the pt while she was on the lift and I was so overwhelmed and stressed and I felt like the resident was not in danger, I misjudged the situation. I really wish I waited this extra couple of minutes but I was just so tired and I had already missed half an hour of my break so I was impatient. I know that is no excuse but I really thought the resident would be okay with the aid and she wasn't in danger. I had asked the resident if she was ok before I left and she said yes and I asked the aide if it was ok if I go and she said yes. I really regret this so much and I know there's nothing that I can do to fix or change this.

I know I have to wait for what the state says but I don't know how to handle this. I don't know if I will lose my certification or what they will do. It was never my intention to hurt the resident and if the aide asked me to stay or I felt the resident was unsafe I would have stayed.

You only played " half of the ball game, for foolish reasons "

NurseBlaq

1,756 Posts

I need some advice on what will happen to me. I am a cna and recently I was involved with an incident that resulted in the resident falling from the stand up lift and breaking her hip. I was helping an aide transfer a resident from the chair to the bed and when the resident was standing up in the lift, I asked the aide if it was ok for me to go on break and she said yes. I left before the resident was transferred in bed and she was still standing. When I came back from break she told me the resident fell from the lift when I wasn't there.

The facility sent the information to the attorney general and department of health for nys.

I was suspended from work and I understand I am in big trouble but does anyone know the process or what will happen? Will I lose my certification and can I continue nursing school?

I know now I shouldnt have left and I really regret it and I'm so upset that the patient fell I feel so bad. But I don't know what to do and I can't stop thinking about this. Does anyone have any advice or information on what will happen?

You left when there was a need for 2 CNAs. You started helping then left midway. Your break was not that important. There is no way out of this, you are as guilty as they come. You may definitely lose your CNA certification, as far as nursing school I'm unsure. However, if I remember, there is something to the effect of being fired, charged, losing a license etc on the BON application. I may be wrong, but there's definitely something to that effect on there.

Also, the facility will throw you under the bus, rightfully so, because you knew better and left the scene when the patient wasn't in bed. The other CNA telling you things were OK is irrelevant, you knew better! Sorry to say but you're wrong and they will most definitely fire you at minimum.

NurseBlaq

1,756 Posts

I can relate to this 100%. A lot of tasks start with two staff members and end with one finishing up while the other moves on. You got very unlucky.

Can but then I can't. You can't start a blood transfusion then say the patient didn't react the first 5 minutes and I was so hungry and missed half my break that I left and they were OK. Only to come back and find out 10 minutes in they started having a severe reaction. There's no excuse for that. She's in nursing school, that's fundamentals 101! When you start a procedure you see it through to the end, not leave halfway through because you're worried about a break. How many times have we gone without breaks? You get them in when you can and make do the best way you can.

I don't want to sound heartless here because I've been a CNA but I also remember days where you had to squeeze breaks in when you could. There's no excuse for this.

Have Nurse

Have Nurse, ADN, RN

Specializes in Med/Surg/Infection Control/Geriatrics. Has 32 years experience. 15 Articles; 719 Posts

You may wish to sit down with your Supervisor and ask what the written policy is regarding things such as this. You already know that you did something very wrong and that your aide also needs some accountability. I also question the training that you've received in that SAFETY first is always in the forefront. I am sure that you will never make this mistake again.

I doubt that it would affect your schooling though, as they are separate.

The good news is that your weren't fired, only suspended. As far as your certification goes, I'd be surprised if anything happened to it.

Since when does an aide give permission to go on break?

Your issue here was lack of judgment.

You may be required to do some extra training. If you were my employee, I would require you to assist in giving a class to your peers on safe transfers, technique, and situations when a resident MAY NOT be left with one caregiver when two are required.

I would also put you on a 90 day probationary period even if you are already a regular employee.

It wouldn't hurt to seek the advice of an attorney in the event that the family wants to sue. The consult is usually free.

brillohead, ADN, RN

Specializes in Cardio-Pulmonary; Med-Surg; Private Duty. Has 5 years experience. 1,781 Posts

Here's something I haven't seen addressed yet:

Is it the facility's policy that all patients are a two-person transfer?

Or was this particular patient listed as requiring two people?

Because the sit-to-stand lift (or whatever-you-want-to-call-it) is typically meant to be used by just one person, unless there are extenuating circumstances. It is also meant to be used only by patients who can support their weight while standing on the lift, unlike a Hoyer-type sling lift for people who aren't able to stand reliably.

If the patient is normally transferred with just one person, if the patient is normally able to transfer with just one person assisting, if the facility policy is for the sit-to-stand to be operated by only one person, and if you weren't actively training/precepting the other aide, then there is no reason for you to be there, so taking your break mid-transfer would not be a problem.

But if the policy states that two people must be there for all lift usage, or if you were training the person and abandoned them mid-transfer, or if the patient normally needs two people for a transfer, then that is on you for leaving mid-transfer.

We weren't there, we don't know the patient, we don't know your facility, and we don't know your state's certifying authority, so we can't answer as to what is going to happen to you.

But your level of "fault" in the whole thing depends on your facility's policies (two for a lift?), your patient's known history (one or two people for transfers), and your status (training/precepting?) with to the other aide.

Neats

Neats, BSN

Specializes in Case Manager/Administrator. Has 13 years experience. 682 Posts

Most lifts I know take 2 people. In this case with a Sit/Stand Mechanical Lift it still takes 2 people. Yes you made a bad decision. Learn form this. With that said I do not think you should be penalized for the rest of your life. It shows the importance of following policy/procedure they are there for a reason.

I would hire an attorney and fast. Not trying to scare you as this was not intentional but the family can turn around and sue you. You need to have all the best possibilities you can have to make a sound decision and protection. I would continue to seek an attorney for advise if you cannot afford one you need assistance with this.

NurseBlaq

1,756 Posts

Here's something I haven't seen addressed yet:

Is it the facility's policy that all patients are a two-person transfer?

Or was this particular patient listed as requiring two people?

Because the sit-to-stand lift (or whatever-you-want-to-call-it) is typically meant to be used by just one person, unless there are extenuating circumstances. It is also meant to be used only by patients who can support their weight while standing on the lift, unlike a Hoyer-type sling lift for people who aren't able to stand reliably.

If the patient is normally transferred with just one person, if the patient is normally able to transfer with just one person assisting, if the facility policy is for the sit-to-stand to be operated by only one person, and if you weren't actively training/precepting the other aide, then there is no reason for you to be there, so taking your break mid-transfer would not be a problem.

But if the policy states that two people must be there for all lift usage, or if you were training the person and abandoned them mid-transfer, or if the patient normally needs two people for a transfer, then that is on you for leaving mid-transfer.

We weren't there, we don't know the patient, we don't know your facility, and we don't know your state's certifying authority, so we can't answer as to what is going to happen to you.

But your level of "fault" in the whole thing depends on your facility's policies (two for a lift?), your patient's known history (one or two people for transfers), and your status (training/precepting?) with to the other aide.

I disagree. Every lift requires 2 people. That is evident from the CNA requesting help in the beginning. Also, you can't begin to assist then stop midway through because you're worried about a break. Lastly, training aside, this patient is clearly not able to stand and hold on, therefore should not be using the lift system, and instead a regular hoyer should have been used. This last point isn't on the CNAs to determine, but nursing staff. However, we know the facility will throw someone under the bus to CYA, in this instance it appears to be OP whom they can find fault in without a doubt. They'll more likely play down everything else and try to focus on the fact OP left midway through caring for the patient.

Horseshoe

Horseshoe, BSN, RN

5,879 Posts

I would hire an attorney and fast. Not trying to scare you as this was not intentional but the family can turn around and sue you.

Doubt it. They go for the deep pockets, not individuals, particularly not unlicensed personnel who are unlikely to have assets worth going for. They will sue the facility and parent company if there is one and insurance will make any payouts.

Ruas61, BSN, RN

Specializes in MDS/ UR. Has 40 years experience. 1,368 Posts

In my state, I have seen CNAs be disciplined with removal of licensure and criminal charges filed in some cases. You get a ding of great magnitude it impacts your ability to pursue other licensures. That's my state though, not in NY. Good luck.

EaglesWings21, ASN, RN

Specializes in Medical Surgical. 380 Posts

I hope this works out for you. You may need to hire an attorney but you haven't even had any action taken against you at this point so I'm not sure if that would be necessary. You could at least try to get in touch with an attorney.

When working with some techs they often stand around while I'm doing something with the patient or tell me they will leave and come back if im doing something only I can do. Teamwork means each team member finding a share in the work. You could have made many different decisions such as help clean the patient up, pick up trash, get the new depends ready, get the bed in position for her to get back in it, but instead you went on break. That's on you and I think you realize that now.

crazin01

crazin01

Specializes in tele, ICU, CVICU. Has 12 years experience. 280 Posts

You should not have left for a break, until when the patient was not safe in bed/chair etc. However, I'm curious about the break occurring rite then. Were you told by supervisor you MUST take break, to avoid any OT? Certainly not an excuse, but I cant help but wonder the plan was regarding breaks...

I think you'll most definitely not repeat this mistake & and feel bad enough already.

Please let us know how things progress, AFTER any trial/legal event is concluded.

Best of luck.

kbrn2002, ADN, RN

Specializes in Geriatrics, Dialysis. Has 20 years experience. 3,660 Posts

I disagree. Every lift requires 2 people. That is evident from the CNA requesting help in the beginning. Also, you can't begin to assist then stop midway through because you're worried about a break. Lastly, training aside, this patient is clearly not able to stand and hold on, therefore should not be using the lift system, and instead a regular hoyer should have been used. This last point isn't on the CNAs to determine, but nursing staff. However, we know the facility will throw someone under the bus to CYA, in this instance it appears to be OP whom they can find fault in without a doubt. They'll more likely play down everything else and try to focus on the fact OP left midway through caring for the patient.

But this is not the case, every lift does not require two people. Actually few mechanical lifts require two staff. First place to reference is the facility policy, if it is facility policy that two people be present for all mechanical lifts then yes, leaving before the lift was completed is against policy and OP can expect being fired at the least. If facility policy does not require two staff be present then the standard is checking each patients/residents care plan to determine the policy for lifting that person. Every facility should have a system in place for staff to reference, usually a Kardex or something similar.

If this patient was not required to have two staff present but was having enough difficulty with the sit-to-stand that the CNA felt the need to ask for help in the first place that lift may not have been appropriate for the patient, but what lift is appropriate isn't the CNA's decision to make. If that lift wasn't safe for that patient the failure was at a level above the CNA using the lift as long as the lift was being used correctly.

Edited by kbrn2002