Failure to Use Required Mechanical Lift Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia and a communication deficit, was transferred by a CNA using a single-person standing pivot transfer instead of the required two-person mechanical lift. The resident's care plan and MDS assessment both specified that transfers should be performed with two staff members using a mechanical lift. During the improper transfer, the resident's left leg rubbed against the bed frame, resulting in a laceration that required 13 stitches and hospital treatment. The CNA involved was unaware of the transfer requirements indicated in the MDS assessment and did not follow the established care plan. Interviews and record reviews confirmed that the CNA had previously used the mechanical lift but failed to do so during this incident. The facility's policy required the use of a mechanical lift for safe transfers, and the DON acknowledged that not following the MDS assessment could result in resident injury. The incident was documented in progress notes, and the resident was able to communicate pain following the transfer, prompting emergency medical attention.