Failure to Follow Two-Person Mechanical Lift Policy Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident who required mechanical lift transfers was moved by a single certified nurse aide (CNA), contrary to the facility's policy mandating two staff members for such transfers. The resident, who was cognitively intact and dependent on staff for transfers due to diagnoses including hypertensive heart and chronic kidney disease with heart failure, was being transferred from bed to wheelchair using a Hoyer lift. During the transfer, the lift tipped over, causing the resident to fall to the ground while still in the lift. The CNA involved reported that the resident typically requested only one CNA for transfers and that this practice was common among staff, despite the policy requiring two staff members. The incident was documented in the resident's progress notes, which described the fall and subsequent assessment revealing tenderness to the head and back. The CNA's statement confirmed that she was the only aide assigned to the resident's hall at the time and that she attempted the transfer alone, as was reportedly the resident's preference. Other staff members interviewed confirmed their understanding of the two-person policy for mechanical lifts and stated that they would call for assistance when needed. The resident also confirmed that she had previously requested single-person transfers but acknowledged the incident and stated that staff now use two people for her transfers. Review of facility records showed that the CNA involved had received training and signed an agreement to follow the lift safety policy, which explicitly required two staff for mechanical lift transfers. Staff competency records indicated that all nursing staff had been assessed as competent in using mechanical lifts. Staffing records for the day of the incident showed that there were multiple aides and nurses on duty, suggesting that additional help was available. The deficiency was identified through observation, interviews, and record review, which established that the facility failed to ensure adherence to its own policy, resulting in an unsafe transfer and a fall.