Failure to Provide Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan and facility policy requiring two-person assistance for transfers using a stand-up lift for a resident with a history of left total knee replacement, dementia, mood disorder, and depression. The resident's care plan specified two-person assistance due to weakness and combative behaviors, and the facility's policy mandated two staff for mechanical lift transfers. On the day of the incident, the resident was transferred multiple times, including from bed to wheelchair, wheelchair to shower chair, and back, with at least one transfer observed to be performed by a single CNA without the required second staff member present. Interviews confirmed that only one staff member was present during at least one transfer, despite the resident's need for two-person assistance for safety. Following these transfers, the resident was found to have swelling, pain, and an acute displaced distal femur fracture, as confirmed by x-ray. The incident investigation determined the injury occurred during a transfer, and staff interviews revealed inconsistencies regarding who assisted with each transfer. The failure to provide adequate supervision and follow established transfer protocols directly led to the resident's injury.