Failure to Follow Two-Person Mechanical Lift Transfer Protocol
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency occurred when a resident, who was severely cognitively impaired and dependent on staff for transfers, was transferred using a sit-to-stand mechanical lift by only one Certified Nursing Assistant, despite the resident's care plan specifying that two staff members were required for such transfers. The incident was observed while the resident was being moved from the toilet to a wheelchair. Interviews with two Licensed Practical Nurses and another Certified Nursing Assistant confirmed that facility protocol and the resident's care plan required two staff members for mechanical lift transfers. The failure to follow the care plan and facility policy resulted in the resident being transferred without adequate supervision.