Failure to Ensure Staff Competency in Safe Use of Lifts Results in Resident Injury
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate training and competencies to safely use manual and mechanical lifts for resident transfers, resulting in a serious injury to a resident. One resident with a history of multiple strokes, obesity, and unilateral functional limitations was care planned for transfer with a manual sit-to-stand lift. The resident sustained a left heel bone fracture after her foot was not properly placed on the lift during a transfer, despite her attempts to alert staff to the improper positioning. Documentation revealed that staff did not have up-to-date or adequate training and competency evaluations for the use of the lifts, and there was no evidence that staff were assessed for competency with the specific equipment in use at the facility. Interviews with staff and review of personnel files showed that several CNAs and licensed nurses had not received recent or documented training on the safe use of manual and mechanical lifts. Some staff reported not having had lift training for several years, and others were unable to demonstrate or explain proper use of the equipment. Observations of transfers revealed improper techniques, such as residents' feet not being fully placed on the footrests, and the use of damaged slings with missing labels and frayed straps, contrary to manufacturer instructions and facility policy. The facility's own policies required staff to be trained and demonstrate competency with each type of lift, and to discard any worn or damaged slings, but these procedures were not followed. The lack of documented training, competency assessment, and adherence to manufacturer and facility protocols placed all residents requiring lift transfers at risk of serious harm. The surveyors determined that these failures resulted in Immediate Jeopardy, as evidenced by the injury to the resident and the ongoing use of unsafe practices and equipment. The facility was unable to provide documentation of staff education, competency verification, or timely investigation and reporting of the incident, further contributing to the deficiency.