Failure to Ensure Safe Mechanical Lift Transfers and Adherence to Manufacturer Guidelines
Penalty
Summary
The facility failed to provide safe mechanical lift transfers for residents dependent on such equipment, resulting in accident hazards and inadequate supervision. In one incident, a resident with quadriplegia, a history of traumatic brain injury, and chronic respiratory failure required a mechanical lift for all transfers. During a transfer, a nursing aide attempted to use the mechanical lift alone, despite facility policy and the resident's care plan requiring two staff members. The aide proceeded without assistance, and the lift's battery failed during the transfer. While attempting to maneuver the resident, the lift swung and struck the resident's forehead, causing a hematoma. The resident was subsequently lowered to the floor and transported to the hospital for evaluation. Interviews and witness statements confirmed that only one staff member was present during the transfer, and the aide had asked another staff member to falsely state she was present. In a separate incident, staff failed to follow the manufacturer's guidelines for the use of a mechanical lift during a transfer of another resident with quadriplegia. Observations revealed that two aides transferred the resident from a wheelchair to a bed without widening or locking the base of the mechanical lift, as required by the manufacturer's instructions. The lift was pushed tightly around the wheelchair, causing it to become stuck, and the unit manager had to maneuver the wheelchair to release it. Interviews with the involved staff confirmed that they did not ensure the base was widened or the wheels locked during the transfer, despite being aware of the correct procedure. Both incidents demonstrate a failure to adhere to facility policy and manufacturer guidelines for mechanical lift use, resulting in unsafe transfer practices. The deficiencies were identified through observation, record review, and interviews with residents and staff, affecting two of three residents reviewed for accident hazards, supervision, and device use.