Single-Staff Mechanical Lift Transfer Performed Against Policy
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident from a shower chair to bed using a mechanical Hoyer lift without the required assistance of a second staff member. The resident involved had diagnoses including congestive heart failure, depressive disorder, and age-related osteoporosis, and was assessed as totally dependent on staff for activities of daily living. The resident's care plan specified the use of a Hoyer lift for transfers due to limited physical mobility, and the facility's policy required at least two nursing assistants for safe operation of the mechanical lift. During observation, the CNA was seen performing the transfer alone, and later confirmed in an interview that he believed it was permissible to use the Hoyer lift with only one person. However, both a licensed vocational nurse (LVN) and the director of nursing (DON) stated that two staff members are required for such transfers to ensure resident safety. Review of facility policy further confirmed this requirement. The failure to follow established procedures placed the resident at risk during the transfer.