Failure to Develop and Implement Comprehensive Care Plans for Mechanical Lift Transfers
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents who required the use of a mechanical lift for transfers. For the first resident, who had a history of hemiplegia, hemiparesis, muscle weakness, contractures, and osteoarthritis, the assessment indicated a need for a total lift with a full body, extra-large sling. However, there was no documented care plan addressing the use of the mechanical lift or specifying the appropriate sling size. This omission led to an incident where two CNAs used an incorrect, smaller sling, resulting in the resident slipping out of the sling and falling, causing a head injury. Interviews with the CNAs revealed they were not trained on sling sizes or proper use, and the care plan did not provide guidance on these critical details. For the second resident, who was dependent for all transfers due to quadriplegia and multiple contractures, the assessment indicated the need for a total lift with a full body, medium-size sling and two-person assistance. Despite this, there was no care plan developed or implemented to address the use of the mechanical lift for this resident. During an observation, a CNA was seen transferring the resident alone with the mechanical lift, contrary to facility policy and the resident's needs. The CNA acknowledged awareness of the two-person requirement but proceeded alone due to other staff being busy, placing the resident at risk. Both cases demonstrated a lack of individualized, comprehensive care planning in accordance with resident assessments, facility policy, and manufacturer instructions. The absence of clear, documented care plans specifying the correct equipment and procedures for mechanical lift transfers contributed to unsafe practices, including the use of incorrect sling sizes and insufficient staff assistance during transfers. These deficiencies were confirmed through record reviews, staff interviews, and direct observation.