Mechanical Lift Transfer Performed by Single Staff Member Results in Resident Fall
Penalty
Summary
A deficiency occurred when a nurse aide (NA) performed a mechanical lift transfer alone, contrary to facility policy and the resident's care plan, resulting in a fall. The resident involved had multiple diagnoses, including contractures of both knees, lack of coordination, Parkinson's disease, muscle weakness, and required assistance with personal care. The resident was assessed as cognitively intact but dependent for transfers, with a care plan specifying the use of a mechanical lift with two-person assistance due to a history of falls and poor balance. On the day of the incident, the NA transferred the resident from bed to wheelchair using a mechanical lift without a second staff member present. During the transfer, the resident was not properly positioned in the lift sling, causing her to be at an angle and subsequently slide out of the sling. The NA lowered the resident to the floor and sought help. The resident reported pain and was sent to the hospital for evaluation, though no injuries were noted at the time. Interviews confirmed that the NA was not aware of the requirement for two staff members during mechanical lift transfers and that the facility's policy and the Director of Nursing's expectations were not followed. The facility's Safe Transfers policy and the resident's care plan both required two caregivers for mechanical lift transfers to ensure safety, but this protocol was not adhered to during the incident.