Failure to Ensure Required Staff Assistance During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that required staff assistance was utilized during mechanical lift transfers for multiple residents, as observed and documented in the clinical records and through staff interviews. For one resident with metabolic encephalopathy, dementia, and renal failure, staff were observed transferring the resident from the bathroom to a wheelchair using a mechanical lift with only one staff member present, despite care plans, physician orders, and facility policy requiring two staff for such transfers. The nurse aide involved acknowledged awareness of the two-person requirement but proceeded alone, and this was confirmed by interviews with other staff and review of facility policy. Another resident with Alzheimer's disease, aphasia, muscle weakness, and chronic kidney disease suffered a left tibia and fibula fracture following a mechanical lift transfer performed by a single nurse aide. The aide did not use the required leg support straps and failed to ensure the resident's feet remained on the lift platform, resulting in the resident's leg slipping and subsequent injury. Documentation and interviews confirmed that the resident required two staff for transfers and that the lift's safety features were not properly used. The incident was not initially acknowledged in the facility's reportable event documentation, and the aide admitted to performing the transfer alone due to lack of available assistance. A third resident with dementia, diabetes, anemia, and hemiplegia was also transferred using a mechanical lift by a single staff member, contrary to care plan instructions and facility policy. The staff member stated she was trained by other staff that only one person was needed, despite documentation and interviews with the DNS, staff development nurse, and physical therapist confirming the two-person requirement. These failures to follow established protocols and care plans for mechanical lift transfers resulted in unsafe conditions and, in one case, resident injury.