Failure to Perform Safe Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to perform a safe mechanical lift transfer for a resident with dementia, heart failure, hypertension, and anxiety. The resident, who weighed 250.2 pounds and was at risk for falls with impaired physical mobility, required assistance with transfers. During an observed transfer from bed to a high back wheelchair, the CNA did not open the legs of the mechanical lift to the wide position before lifting and moving the resident, contrary to facility policy and manufacturer guidelines. The transfer was conducted with the lift pad already under the resident, and both CNAs attached the straps to the mechanical lift. The primary CNA lifted the resident without spreading the lift legs, then moved the resident suspended in the lift pad out from over the bed and toward the wheelchair. The legs of the lift were only spread to the wide position after the resident was already being moved, following a prompt from the assisting CNA. The resident was then lowered into the wheelchair and positioned for comfort. Interviews with the assisting CNA, the primary CNA, the DON, and the administrator confirmed that the mechanical lift legs should be opened wide prior to lifting for stability and to prevent tipping. The facility's policy and FDA best practices both require the lift base to be at its maximum open position during transfers. The DON was unable to locate the mechanical lift competency check-off form for the CNA who performed the transfer.