Failure to Assess and Safely Transfer Resident Using Mechanical Lift
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess a resident's transfer needs and did not develop or implement adequate policies to ensure safe and supervised transfers using a mechanical lift. The resident in question had severely impaired cognition, limited function in the right arm and hand, used a wheelchair, required maximal assistance for mobility, and was on hospice care. The care plan indicated the need for one to two staff for transfers with a mechanical lift, but the electronic medical record did not reflect a reassessment of transfer needs when the mechanical lift was used. Multiple observations showed the resident being transferred with a mechanical standing lift despite being unable to bear weight and having only one functional hand to hold the lift handle. Staff interviews revealed inconsistent understanding of the criteria for using the mechanical lift, with some staff expressing discomfort with the transfer process and others stating the resident met the criteria. During transfers, the resident was observed hanging from the lift, unable to support themselves, and required staff to lift their legs onto the foot plate. The director of therapy confirmed that the resident did not meet the qualifications for the mechanical standing lift and should not have been using it. Facility policies required that residents be able to bear weight and hold onto the lift handles to be suitable for standing transfers. However, the staff failed to identify that the resident's transfers were unsafe and did not refer the resident for a therapy reassessment when their abilities changed. The director of nursing acknowledged that while staff were aware of the transfer process, they did not recognize unsafe transfers, leading to the deficiency.