Failure to Provide Safe Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for transfers due to morbid obesity, diabetes type 2, congestive heart failure, and limited range of motion in both lower extremities, was transferred using a mechanical lift by only one staff member, contrary to the care plan and facility policy requiring two staff for such transfers. During the transfer, the resident expressed concerns about back pain and the manner in which the transfer was being conducted. The staff member performing the transfer became upset, left the resident suspended in the mechanical lift sling above the shower chair, and exited the room, leaving the resident unattended and unable to reach the call light. The resident remained in the lift for approximately ten minutes, calling for help until two other staff members responded and completed the transfer. The resident was not physically injured or emotionally traumatized by the event, as reported in interviews, but the incident was not documented in the nursing progress notes, and no incident report was filed at the time. The staff member involved admitted to routinely performing transfers alone and stated he left the room to de-escalate the situation after the resident became verbally aggressive. Interviews with other staff confirmed that the transfer was performed by a single staff member and that the resident was left suspended in the lift. The facility's policy and the resident's care plan both required two staff members for mechanical lift transfers to ensure safety. The incident was reported to facility management the following morning, but there was a lack of immediate documentation and notification by the staff present at the time of the event.