Injury During Mechanical Lift Transfer Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, neuroleptic-induced parkinsonism, and significant functional limitations was being transferred using a mechanical lift by two CNAs. During the transfer from a specialized chair to the bed, the resident became agitated and moved around, resulting in his right foot striking the footboard of the bed. This incident caused a laceration to the resident's right fifth toe, which required hospital treatment and sutures. Staff interviews revealed that two CNAs were present during the transfer, with one operating the mechanical lift and the other guiding the resident. Both staff members acknowledged the need for careful monitoring during mechanical lift transfers, especially for residents who are dependent and may become anxious or impulsive. The DON stated that the staff should have stopped the transfer and notified the nurse when the resident became agitated, but this did not occur, leading to the injury. Documentation confirmed that the resident was dependent for all ADLs and required substantial/maximal assistance, with a care plan specifying the use of a mechanical lift and two-person assist for transfers. The facility's policy also required two staff for safe mechanical lift operation. Despite these protocols, the resident sustained an injury during the transfer due to inadequate supervision and failure to appropriately respond to the resident's agitation.