Failure to Follow Two-Person Mechanical Lift Protocol
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a mechanical lift without the required two-person assist. The resident, who had a care plan indicating a self-care performance deficit due to dementia, confusion, activity intolerance, and impaired balance, was observed suspended in a mechanical lift sling over the bed while the CNA prepared the resident's wheelchair. The CNA admitted to performing the transfer alone because other staff were unavailable, despite facility policy and care plan interventions mandating two staff members for all mechanical lift transfers. The facility's policy on safe resident handling and transfers, as well as facility-wide education (which the CNA had signed), clearly state that two staff members must be present when using a mechanical lift. The administrator and DON confirmed that this protocol is required at all times. The failure to follow the care plan and facility policy resulted in the resident being transferred without the necessary assistance, as directly observed and documented by surveyors.