Failure to Ensure Safe Resident Transfers Due to Faulty Equipment
Penalty
Summary
The facility failed to ensure that residents were transferred safely using properly functioning equipment, as evidenced by multiple incidents involving three residents. Staff used a sit-to-stand machine and a mechanical lift with a non-functioning emergency release and unreliable batteries. In one instance, a CNA attempted to lower a resident onto the toilet using the sit-to-stand machine, but the battery died and the emergency release did not work. The CNA had to manually lower the resident to a wheelchair, and the broken equipment was not removed from use or labeled as defective. Staff reported that management had been informed about the unreliable equipment, but no immediate action was taken to prevent further use. Additionally, staff continued to use the same malfunctioning mechanical lift to transfer other residents, despite being aware that the emergency release was not operational. The care plan for one resident specified the use of a mechanical lift due to cognitive impairment and physical limitations, but staff attempted a sit-to-stand transfer without a proper assessment or care plan update. Maintenance staff later confirmed the emergency release was not attached as required, and the facility's maintenance policy indicated responsibility for keeping equipment safe and operable at all times.