Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to perform a safe mechanical lift transfer for a resident with a history of falls, confusion, deconditioning, gait and balance problems, incontinence, and poor communication and comprehension. The resident was known to be unaware of safety needs and exhibited jerking movements and agitation during transfers. On the day of the incident, two CNAs attempted to transfer the resident from a wheelchair to a bed using a full body mechanical lift. The resident was observed to be slouched and lying on her right side in the wheelchair, and staff did not reposition her to an upright position before applying the sling and initiating the lift. During the transfer, the sling was not properly centered, and the resident remained in a side-lying position while being lifted. One CNA operated the lift controls while the other removed the wheelchair from beneath the resident, leaving her suspended in the sling without support. At this point, neither CNA maintained physical contact with the resident. As the lift was moved, the resident rolled through the lift straps and fell face forward out of the sling, hitting her head and body on the legs of the lift and the floor. The incident was witnessed by another resident and captured on video, which confirmed that the resident was not properly positioned and that staff did not maintain appropriate supervision or physical support during the transfer. Interviews with staff revealed a lack of understanding regarding proper sling sizing, positioning, and the need for additional assistance during transfers for residents with unpredictable movements. Staff acknowledged that the resident required close supervision and sometimes three or more people to ensure safety during transfers. Despite this, only two staff members were present, and they did not follow established procedures for safe mechanical lift use, including ensuring the resident was upright and centered in the sling and maintaining contact throughout the transfer. The failure to adhere to these safety protocols directly led to the resident's fall from the lift.