Failure to Follow Mechanical Lift Protocols During Resident Transfer
Penalty
Summary
Staff failed to follow established procedures for the use of a mechanical stand-up lift when assisting a resident with hemiplegia and moderate cognitive impairment. During an observed transfer, the staff member did not secure the leg strap around the back of the resident's legs as required by facility policy and manufacturer instructions, instead placing it around the leg rest. Additionally, the resident's feet were not properly positioned on the footrest, with one foot partially out of a slipper and the other heel hanging off the footrest. These actions were inconsistent with the facility's policy and training materials, which specify that the leg strap should be fastened behind the legs and both feet should be flat on the footrest for safety and stability. Interviews with multiple staff members, including nursing assistants, therapy staff, and management, confirmed that the correct procedure for using the stand-up lift involves securing the leg strap behind the resident's legs and ensuring both feet are flat on the footrest. Staff acknowledged that failure to follow these steps could compromise resident safety. Despite this, the staff member involved in the incident believed her method was correct, indicating a lack of understanding or adherence to the established protocol. The resident involved required substantial assistance for transfers due to physical and cognitive limitations, as documented in the care plan and assessment records. The failure to use the assistive device according to policy and training, and to properly position the resident, resulted in a situation where the resident was not adequately protected from accident hazards during the transfer process.