Unsafe Mechanical Lift Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a sit-to-stand mechanical lift without following established safety protocols. The resident, who had multiple medical conditions including generalized weakness, lymphedema, obesity, gout, osteoarthritis, and physical debility, was unable to fully grip the lift's grab bar due to swelling and pain in her left hand. Despite the resident's repeated attempts to inform the CNA of her inability to hold on, the CNA proceeded with the transfer alone, without the required safety belt and without a second staff member present. During the process, the resident lost her grip and fell to the floor. The facility's policy requires that mechanical lifts be operated by two trained staff members and that the safety belt always be used. Interviews with facility leadership confirmed that all CNAs are trained and must pass competency evaluations for lift use, but documentation of the CNA's training could not be located. The incident was not documented in the resident's nurse notes, but subsequent reports to the state health department confirmed the fall and the resident's resulting pain and medical evaluation.