Mechanical Lift Transfer Conducted Without Required Two-Person Assistance
Penalty
Summary
A deficiency occurred when a staff member used a mechanical lift to transfer a resident without the required assistance of a second staff member, as mandated by the facility's policy and procedure for safe resident handling and transfers. During an observation, a restorative nursing assistant was seen operating the mechanical lift alone while transferring a resident who was dependent on two-person assistance for all activities of daily living, including transfers. The resident was lifted above the bed using a sling attached to the mechanical lift, with no other staff present in the room. The resident involved had multiple medical conditions, including acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus with hyperglycemia, and acute pulmonary edema. The resident's care plan and assessment indicated a need for total assistance from two staff members for transfers due to confusion and impaired balance. Both the staff member involved and the Director of Staff Development confirmed that facility policy requires two staff members to be present when using a mechanical lift, with one operating the lift and the other supporting the resident. The facility's policy, revised in December 2022, explicitly states that two staff must be utilized for mechanical lift transfers to ensure safety.