Failure to Follow Mechanical Lift Safety Protocols During Resident Transfer
Penalty
Summary
Staff failed to ensure a safe transfer for a resident with morbid obesity, intellectual disabilities, and osteoarthritis by not following manufacturer specifications for the use of a mechanical lift. The resident's care plan required the use of a mechanical lift for transfers, and the facility's policy, as well as the manufacturer's guidelines, directed that the base legs of the lift be locked in the maximum open position for stability and safety. During an observed transfer, two nurse aides did not open the base of the mechanical lift before moving the resident out of bed. Interviews with the nurse aides revealed that they were unaware of the importance of opening the base of the lift prior to use, and one aide stated she was not taught to do so. The Director of Staff Development indicated that all staff receive in-service training on the use of the mechanical lift upon hire, and both aides had been oriented to its use. Facility documentation confirmed the policy requirement for the base to be open during transfers, and the manufacturer's guidelines emphasized the need for the base to be in the maximum open position to prevent tipping and ensure resident safety.