Neglect in Mechanical Lift Transfers Resulting in Resident Injury
Penalty
Summary
The facility failed to protect residents from neglect related to the improper use of mechanical lifts during transfers, affecting two residents who were dependent on such equipment. One resident, with severe cognitive impairment and total dependence for transfers, was not properly assessed for mechanical lift use, and staff were not adequately educated on correct transfer methods. On the day of the incident, two CNAs transferred the resident using a mechanical lift, after which significant pain and a displaced right hip were observed. The resident was sent to the hospital, where a displaced spiral subtrochanteric fracture of the right femur was diagnosed, requiring surgical intervention. Interviews revealed that staff had not received formal training or competency demonstrations on mechanical lift use, and there was confusion regarding responsibility for assessing residents and selecting appropriate sling sizes. Another resident, who was cognitively intact and also dependent on mechanical lift transfers, was observed being transferred by a CNA using the mechanical lift alone, contrary to facility policy requiring two staff members for such transfers. The resident expressed feeling nervous about being transferred with only one staff member present. Review of the resident's care documentation showed that the number of staff required for transfers was not specified, and staff interviews confirmed a lack of clarity and adherence to the two-person transfer policy. Facility policies required at least two staff for mechanical lift transfers and mandated staff training and competency in the use of such equipment. However, interviews with staff and review of training records indicated that training was informal, often provided by other aides rather than through structured demonstration or competency assessment. The lack of proper assessment, documentation, and staff education directly contributed to the neglect and subsequent injury, as well as the unsafe transfer practices observed.