Failure to Provide Required Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident was transferred using a mechanical lift by only one certified nurse aide (CNA), despite facility policy and the resident's care plan both requiring the assistance of two trained staff for such transfers. The CNA placed the resident in the lift sling, raised the lift, and began to move the resident into position to transfer her to a chair. During this process, the resident slid out of the sling head first and fell to the floor, sustaining a scalp abrasion and acute headache, as documented by a physician's progress note. Eyewitness accounts from the resident's roommate confirmed that only the CNA and the resident were present in the room at the time of the incident. The roommate observed the sling swinging before the resident suddenly fell to the ground and began screaming. The CNA admitted to dropping the resident from the sling and acknowledged not having a second staff member present, as required. The incident resulted in visible injury and distress to the resident.