Failure to Follow Two-Person Mechanical Lift Protocols During Resident Transfers
Penalty
Summary
Two residents with severe cognitive impairment and total dependence for activities of daily living, including transfers, were not transferred according to their care plans and facility policy. Both residents required the use of a mechanical lift with assistance from two staff members for all transfers, as documented in their care plans, assignment sheets, and reinforced by care stickers on their doorways. Despite these requirements, a certified nursing assistant (CNA) was observed and reported to have performed mechanical lift transfers alone for both residents on the same day. Multiple staff interviews and documentation confirmed that the CNA did not request or receive assistance from other available staff members, even though at least three to four CNAs and a nurse were present on the hall. The CNA had previously signed off on training and competency evaluations that emphasized the necessity of two-person assistance for mechanical lift transfers. The CNA was observed by both the assistant director of nursing (ADON) and an LPN performing transfers alone, and the CNA admitted to being alone during at least one of the transfers. Manufacturer guidelines for the mechanical lift, facility policy, and staff training all required two staff members for safe operation of the lift, particularly for residents who are non-ambulatory and fully dependent. The failure to follow these protocols resulted in the residents being transferred by a single staff member, contrary to their care plans and established safety procedures. No injuries were reported as a result of these incidents, but the deficiency was identified through staff interviews, documentation review, and direct observation.