Mechanical Lift Transfer Performed by Single CNA Without Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a mechanical lift without the assistance of another staff member, contrary to facility policy and the resident's care plan. The resident in question had diagnoses including dementia, muscle weakness, and vision loss, and was assessed as having a moderate cognitive deficit and being dependent on staff for transfers. The care plan and physician orders specified the use of a mechanical lift for all transfers, but did not indicate that single-staff transfers were permitted. During the observed incident, the CNA operated the lift alone, making multiple adjustments to the resident's position while the resident was suspended in the air, as no other staff were available to assist due to staffing shortages. Interviews with staff confirmed that the CNA performed the transfer alone because other CNAs were occupied with resident care and there were not enough staff available at the time. The LPN on duty was preparing medications and did not assist with the transfer. The facility's policy on safe lifting and movement of residents emphasizes the use of appropriate techniques and devices to ensure safety, but this policy was not followed during the observed transfer. The resident did not report any injury or fall during the transfer.