Failure to Ensure Two-Person Assist During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) performed a mechanical lift transfer of a resident without the required assistance of a second staff member, contrary to facility policy. The resident, who had diagnoses including Multiple Sclerosis, muscle wasting and atrophy, encephalopathy, and neuromuscular dysfunction of the bladder, was dependent for transfers and required a two-person assist for mechanical lift use. During the transfer, the CNA attempted to maneuver the resident into a high back reclining wheelchair alone, resulting in a change in the resident's center of gravity and causing the mechanical lift to tip over. The CNA called for help, and an LPN responded to assist in safely lowering the resident to the floor. The resident was cognitively intact but had significant functional impairments, including limited use of one upper extremity and both lower extremities, and was at risk for falls due to deconditioning and Multiple Sclerosis. The facility's policies clearly stated that two staff members were required for all mechanical lift transfers. Interviews and documentation confirmed that the transfer was performed by a single CNA, in violation of these policies, which directly led to the incident where the resident and CNA became pinned against a dresser and required assistance to resolve the situation.