Failure to Use Two Staff for Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) transferred a resident using a mechanical lift without the required assistance of a second staff member, contrary to facility policy. The resident, who had intact cognition but required maximal to dependent assistance with transfers and mobility due to diagnoses including non-Alzheimer's dementia, congestive heart failure, and arthritis, was being prepared for supper. The CNA, after waiting for his partner, decided to proceed with the transfer alone, placed the sling under the resident, and attached it to the lift by himself. During the process of positioning the resident in a Broda chair, the CNA attempted to unfold the footrest while holding the resident's right foot. He accidentally dropped the resident's foot onto the footrest, resulting in a skin tear to the right fifth toe. The injury was documented as a 3 cm by 1 cm by 0.1 cm skin tear. Staff interviews confirmed that the resident required two staff for safe transfers with a mechanical lift, and that the CNA had performed the transfer alone. The incident was reported to nursing staff, who provided wound care and notified the family, physician, and supervisors. Further interviews and documentation revealed that the facility's policy explicitly required two staff members for mechanical lift transfers. Staff training records indicated that in-services on mechanical lift use and proper foot placement in wheelchairs and Broda chairs had been conducted. Despite these policies and trainings, the transfer was performed by a single staff member, directly leading to the resident's injury during the positioning process.