Failure to Ensure Staff Competency in Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competencies in performing mechanical lift transfers, as evidenced by multiple observed incidents involving two residents who required such transfers. In one case, a resident with severe cognitive impairment, cerebral palsy, and a recent major injury was transferred using a mechanical lift by two CNAs. During the transfer, the resident became restless and maneuvered herself out of the sling, resulting in a fall and a right tibia fracture. Staff interviews and documentation revealed that the CNAs were not adequately trained on selecting the correct sling type or size, and there was confusion regarding the compatibility of slings with the mechanical lift equipment. The slings used were sometimes not appropriate for the resident's needs, and staff were unclear on how to support the resident's fractured leg during transfers. In another observed incident, a resident was transferred from a wheelchair to a bed using a mechanical lift. During this process, the CNA failed to lock the wheelchair and the mechanical lift prior to transferring and lowering the resident, respectively. Additionally, the staff involved were unable to determine the correct size of the lift pad for the resident, and there was no physician order documented for the use of a mechanical lift for this resident. Observations also noted that some mechanical lift slings were not labeled with resident names, and staff reported using slings that were not always the correct size or type due to lack of training or availability. Interviews with various staff members, including CNAs and QMAs, confirmed a lack of knowledge and training regarding the selection and use of mechanical lift slings, as well as the proper procedures for safe transfers. Staff were not consistently aware of manufacturer guidelines, facility policies, or the specific needs of residents during mechanical lift transfers. These deficiencies in staff competency and adherence to policy had the potential to affect all residents requiring mechanical lift transfers in the facility.