Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
The facility failed to implement the care plan for a resident requiring mechanical lift transfers with assistance from two staff members. According to the resident's care plan, mechanical lift transfers with two staff were required for all transfers. However, during a transfer from wheelchair to bed, a certified nurse aide (CNA) did not use the mechanical lift or a second staff member, resulting in the resident sliding to the floor. The resident attributed the incident to wearing socks and reported no pain or injury, denying hitting their head. Review of facility records and staff interviews confirmed that the care plan intervention for mechanical lift with two staff was in place at the time of admission and not followed during the incident.