Failure to Follow Two-Person Mechanical Lift Policy Results in Resident Injury
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) failed to follow the resident's Comprehensive Care Plan (CCP) and facility policy regarding mechanical lift transfers. The resident involved had significant medical conditions, including anemia, peripheral vascular disease, and dementia, and was assessed as severely impaired for decision-making and fully dependent on staff for transfers. The CCP and facility policy both required two staff members to assist with mechanical lift transfers for this resident. Despite these requirements, the CNA attempted to transfer the resident alone using a Hoyer lift. During the process, the CNA placed the sling under the resident without assistance and proceeded with the transfer. The resident began to slide out of the Hoyer pad, and the CNA lowered the resident to the floor. The incident resulted in the resident complaining of severe pain in the right shoulder and hip, and emergency services were called to transport the resident to the hospital. Medical evaluation at the hospital revealed no acute fractures or intracranial hemorrhage, but the resident was diagnosed with a contusion and a urinary tract infection. The facility's investigation confirmed that the CNA was aware of the two-person requirement for Hoyer transfers but proceeded alone because other staff were unavailable at the time. The incident was documented as a failure to implement the care plan and facility policy, resulting in neglect as defined by both facility and federal standards.