Failure to Use Two Staff for Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with vascular dementia and osteoarthritis using a mechanical lift without the required assistance of a second staff member. The resident's care plan specified that transfers with a mechanical lift required two staff, and the resident was dependent on staff for transfers due to medical and safety concerns. Observations showed that the CNA performed both the transfer from bed to shower bed and back without any other staff present, despite the care plan and facility training materials indicating that two staff were necessary for such transfers. Interviews confirmed that the CNA was aware of the requirement but did not follow it, stating that the transfer was easy to perform alone. The Director of Nursing (DON) affirmed that the expectation was for two staff to assist with mechanical lift transfers, and the Administrator acknowledged the absence of a formal policy but provided training materials that also required two staff for these transfers. The failure to follow the care plan and established procedures for safe transfers placed the resident at risk for injury.