Failure to Follow Two-Person Mechanical Lift Protocol Results in Resident Injury
Penalty
Summary
Staff failed to follow the resident's care plan and facility protocol during a mechanical lift transfer for a resident with significant physical dependencies, including hemiplegia, hemiparesis, diabetes, hypertension, dysphagia, and chronic kidney disease. The care plan required a two-person assist and use of a mechanical lift for all transfers. However, a Qualified Medication Aide (QMA) attempted to transfer the resident alone using a mechanical stand-up lift, contrary to the care plan and staff education, which clearly stated that two staff members are required for all mechanical lift transfers. During the transfer, the resident experienced pain and reported a popping sound in the right shoulder, later diagnosed as a subtle nondisplaced supercondylar fracture of the right elbow. The QMA stopped the transfer and sought assistance from a CNA, who helped complete the transfer. Interviews confirmed that staff were aware of the two-person requirement for mechanical lifts, and the assignment sheet and staff education reinforced this protocol. The facility did not have a dedicated policy for mechanical lift safety, but staff education materials reiterated the two-person rule.