Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident was not safely transferred using a mechanical lift, resulting in a fall and injury. The resident, who weighed 324 pounds, was being transferred from bed to wheelchair by a single CNA using a bariatric mechanical lift. The CNA reported that she was alone during the transfer due to being busy, and as she attempted to move the resident, the lift's legs became stuck, causing the lift to tip over. The resident fell to the floor, sustaining a contusion to the right forearm and a head injury, and was subsequently sent to the hospital for evaluation. The resident also experienced a period of unresponsiveness and low oxygen saturation following the fall. Interviews and documentation confirmed that facility policy required two staff members for mechanical lift transfers, but only one CNA was present at the time of the incident. The CNA did not request assistance from other staff, and the LPN on duty was unaware of the transfer until after the fall occurred. The mechanical lift used was later found to have a wobbly boom and was removed from service. The resident's transfer status was not documented in the Kardex at the time of the incident.