Failure to Ensure Safe Transfers and Proper Use of Mechanical Lifts
Penalty
Summary
The facility failed to ensure resident safety during transfers, resulting in harm to a resident who was improperly transferred in the shower room. The resident, who had a history of seizure disorder, prior laminectomy, and was assessed as requiring partial/moderate assistance for transfers, was left standing at the grab bars without a gait belt and without proper footwear. The staff member assisting her turned away to retrieve a shower chair, leaving the resident unsupported, which led to the resident losing her grip and falling. The fall resulted in two fractures, increased pain, and a decline in the resident's ability to transfer. Observations of other residents revealed additional failures in the use of full body mechanical lifts. Staff were observed transferring residents with the adjustable base of the mechanical lift in the closed position, contrary to both manufacturer instructions and facility policy, which require the base to be in the open position for stability during transfers. This improper use caused residents to tilt and the lift to wobble during transfers, creating unsafe conditions. Staff interviews confirmed a lack of understanding regarding the correct positioning of the lift base, and some staff believed the lifts could only be moved with the base closed due to the age of the equipment. Facility documentation and staff interviews indicated that the use of gait belts and proper footwear were required for transfers, but these protocols were not followed during the incidents. The facility's own policies and the manufacturer's manual for the mechanical lift both emphasized the importance of these safety measures. Despite these clear guidelines, staff failed to implement them, resulting in unsafe transfers and resident harm.