Failure to Provide Adequate Supervision and Equipment Assessment During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers due to multiple complex medical conditions including bilateral leg amputations, multiple sclerosis, morbid obesity, legal blindness, and paraplegia, was transferred from a wheelchair to a bed using a mechanical lift by only one staff member. The resident's care plan specifically required two-person assistance for all mechanical lift transfers. Despite this, a CNA performed the transfer alone. During the transfer, the mechanical lift pad's strap tore, causing the resident to fall from the lift to the floor. As a result of the fall, the resident sustained dental injuries, including one missing tooth and another tooth broken in half. The resident was sent to the hospital for evaluation and returned with no other injuries noted, but required follow-up with an emergency dentist. Interviews with the resident, the CNA involved, and the DON confirmed that the transfer was conducted by a single staff member, contrary to the resident's care plan and facility policy, and that the mechanical lift pad failed during the process. The facility's policy required two staff members for mechanical lift transfers and proper assessment of lift equipment prior to use. The lack of adherence to these protocols directly contributed to the incident and resulting harm.