Failure to Ensure Staff Competency in Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that licensed nursing staff and nurse aides were knowledgeable and competent in providing care and services related to safe mechanical lift transfers for dependent residents. Staff interviews revealed that CNAs and LPNs determined the need for mechanical lift transfers by referencing the care planning section of the Kardex, but there were no specific instructions regarding the type or size of sling to use for each resident. Staff selected slings based on general observation and self-assessment, and confirmed they had not received specific education or training on mechanical lift use at the facility. Observations showed that a CNA transferred a resident alone using a mechanical lift, contrary to the requirement for two staff members, and the Kardex did not specify the number of staff required for transfers. For one resident, who was cognitively intact and dependent on staff for transfers, interviews and record reviews indicated that she was routinely transferred by only one CNA, making her feel nervous. The Kardex and care plan for this resident did not accurately reflect her transfer needs. For another resident with severe cognitive impairment and multiple diagnoses, including dementia and osteoarthritis, records showed she was dependent on staff for transfers and required a mechanical lift with two-person assistance. This resident experienced a displaced spiral subtrochanteric fracture of the right femur after being transferred, which was discovered when staff noticed her leg was out of place following a transfer. There was confusion among staff and the primary care provider regarding the cause of the injury, with discrepancies in documentation and reporting. Interviews with facility leadership, including the DON, ADON, and Director of Rehabilitation, confirmed that there was no formal training or competency assessment for mechanical lift use, and that care plans and Kardexes were not updated to reflect residents' current transfer needs. The Director of Rehabilitation stated that therapy did not provide formal training or assessments for mechanical lift use, and the DON acknowledged that training was typically provided informally by other aides. The facility assessment and job descriptions reviewed did not ensure that staff had the necessary competencies to provide safe care for residents requiring mechanical lift transfers.