Failure to Maintain Resident Safety During Mechanical Lift Transfers
Penalty
Summary
Staff failed to ensure an environment free from accident hazards during full body mechanical lift transfers for two residents. In both observed incidents, one staff member operated the lift controls while the second staff member, who was responsible for maintaining hands-on stabilization of the resident, released physical contact and attended to other tasks. Specifically, during a transfer from a recliner to a wheelchair, the second staff member let go of the resident to walk around the lift and stand behind the wheelchair, leaving the resident in a raised and unsupported position. In another instance, during a transfer from a wheelchair to a bed, the second staff member let go of the resident to open a bathroom door and move the wheelchair, again leaving the resident unsupported while the lift was in operation. Interviews with the involved staff confirmed that they would not have performed the lift tasks differently and acknowledged releasing physical control of the residents during the transfers. Licensed nursing staff and administrative personnel stated that proper procedure requires two staff members: one to operate the lift and the other to maintain hands-on contact with the resident at all times for safety. Additionally, the facility's mechanical lift policy lacked specific guidance on maintaining resident contact and proper positioning of the lift legs during transfers.