Resident Left Unattended and Suspended in Ceiling Lift During Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of non-traumatic subarachnoid hemorrhage, hemiplegia, and hemiparesis, who required two-person assistance for transfers, was left suspended in a ceiling lift without adequate supervision. During personal care, a CNA attempted to transfer the resident from bed to wheelchair using a ceiling lift. The lift stopped working when the emergency cord was pulled out, leaving the resident suspended in the air. The CNA left the resident alone in this position to seek help, leaving the resident out of sight and without another staff member present, contrary to the care plan and facility policy. The care plan specified that the resident required two-person assistance with mechanical aid for transfers due to cognitive deficits and decreased strength. Observations confirmed that only one CNA was present during the transfer, and the resident attempted to assist by holding the emergency cord while suspended. Facility policy and the lift manufacturer's instructions both emphasized the need for proper assessment and adequate staff support during transfers, which was not followed in this incident.