Failure to Provide Required Two-Person Assist During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) transferred a resident using an electric stand-up lift without the required assistance of a second staff member. The CNA entered the resident's room alone and used the lift to transfer the resident from a wheelchair to the bed, despite facility policy and the resident's care plan both specifying that a two-person assist was necessary for such transfers. The resident involved had multiple sclerosis, generalized muscle weakness, and severely impaired cognition, and was assessed as needing maximal assistance with transfers and mobility. Interviews with facility staff, including the CNA, Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that two staff members were required to safely operate the electric stand-up lift. The CNA acknowledged being alone during the transfer and stated awareness of the two-person requirement. Facility training records showed the CNA had received in-service education on proper transfer procedures, which included the need for assistance from another staff member. The facility's policy emphasized the resident's right to a safe environment, including safe support for daily living activities.