Failure to Ensure Two-Person Assistance During Mechanical Lift Transfers
Penalty
Summary
The facility failed to prevent the potential for serious harm or injury by not ensuring that mechanical lift transfers were performed according to policy, which required at least two nursing assistants for safe resident movement. Record reviews showed that multiple residents required two-person assistance for transfers using Hoyer or sit-to-stand lifts, as documented in their care plans and Minimum Data Set (MDS) assessments. Despite these requirements, staff interviews and resident statements confirmed that transfers were frequently conducted by a single staff member due to ongoing staffing shortages. Staff, including medication aides and nurse aides, reported that the facility was often understaffed, with shifts sometimes covered by only the DON and a minor nurse aide who was not permitted to use mechanical lifts. Staff admitted to transferring residents alone with mechanical lifts, including both Hoyer and sit-to-stand lifts, because there were not enough staff available to provide the required two-person assistance. This practice was corroborated by resident interviews, who described feeling unsafe and noted that single-staff transfers had become routine. The facility's own policy, revised in July 2017, specified that two staff members were needed for mechanical lift transfers, and this was reflected in the care plans for residents requiring such assistance. However, due to chronic understaffing, staff were unable to consistently follow these protocols, resulting in transfers being performed by one person. This deviation from policy and care plans created a situation where residents were at increased risk during transfers, as confirmed by both staff and resident accounts.