Failure to Follow Two-Person Lift Protocol Results in Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect during a transfer using a full body lift, resulting in injury. According to facility policy, two staff members are required to operate the total lift, with both present and actively assisting throughout the transfer process. On the day of the incident, one CNA attached the resident to the lift before the second CNA entered the room, contrary to the policy and training that require both staff to be present from the beginning. During the transfer, one CNA turned away to retrieve a geri-chair, leaving the other CNA to operate the lift alone. While the resident was being moved, a loud noise was heard, and the resident began to slide out of the sling, ultimately striking her head and sustaining a bleeding injury. Interviews with staff revealed inconsistent understanding and execution of the two-person assist protocol. The CNAs involved gave differing accounts regarding when the second staff member was present and their roles during the transfer. The lift trainer and DON both confirmed that standard procedure requires both CNAs to be positioned at the lift, with one supporting the resident and the other operating the equipment, to ensure safety. However, during the incident, this protocol was not followed, as one CNA was not actively assisting at the lift when the resident slid out. The resident involved had a recent history of a left lower leg fracture and was assessed as requiring a two-person assist for transfers. Following the incident, the resident was found unresponsive with a head injury and was later diagnosed with a subarachnoid hemorrhage. The failure to follow established transfer protocols directly led to the resident's fall and subsequent injury.