Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
Facility staff failed to provide a proper mechanical lift transfer for a resident, resulting in an accident where a television was struck by the lift and fell, causing injury to the resident's head and arm. The facility's policy and the lift manufacturer's manual both require two staff members to assist with mechanical lift transfers, especially for residents with conditions such as obesity, contractures, or combativeness. The resident in question was assessed as cognitively intact, totally dependent for transfers, paraplegic, obese, and required a mechanical lift with two-person assistance for all transfers. Despite these requirements, a Certified Nursing Assistant (CNA) performed the transfer alone. During the transfer, the CNA raised the mechanical lift, which hit the television mounted on the wall, causing it to fall and strike the resident. The CNA acknowledged operating the lift alone and reported the incident to a Registered Nurse (RN), initially stating the television did not hit the resident, but later confirming it struck the resident's arm and head. The resident reported feeling a knot on the head and expressed concern that staff often use only one person for mechanical lift transfers, despite being paralyzed. Interviews and documentation confirmed that the facility's policy was not followed, leading to the accident and injury.