Failure to Use Two-Person Assist for Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident was transferred from a wheelchair to a bed using the required two-person assist, as per the facility's policy. The incident involved a certified nursing assistant (CNA 1) who transferred the resident using a Liko Lift without the assistance of a second staff member. This action was contrary to the resident's care plan, which specified the need for a two-person assist during transfers, and the facility's policy on safe patient handling. During the observation, it was noted that the CNA positioned the Liko Lift next to the resident's bed and proceeded with the transfer alone, despite the requirement for a two-person assist. The CNA confirmed that the resident required two-person assistance for transfers. The Director of Nursing also stated that all staff are trained to use two-person assistance when using the Liko Lift, as indicated in the facility's staff training materials. This failure had the potential to result in an avoidable fall for the resident.