Failure to Provide Adequate Assistance During Mechanical Lift Transfers
Penalty
Summary
Staff failed to provide adequate assistance during mechanical lift transfers for two residents who required such assistance. In one instance, a Certified Nurse Aide (CNA) was observed transferring a resident from a wheelchair to a bed using a Hoyer lift without the required second staff member present. The CNA confirmed during an interview that she performed the transfer alone and acknowledged that two staff members were needed for the procedure. In another case, a different CNA was seen exiting a resident's room with a Hoyer lift, and no other staff were observed. This CNA also admitted to transferring the resident alone, stating she believed it was safe and permitted to do so. The Director of Nursing (DON) confirmed that facility policy does not allow single-staff Hoyer lift transfers. Additionally, a review of the Patient Lift Safety Guide indicated that most lifts require two or more caregivers to operate safely. These observations and interviews demonstrate that the facility did not ensure residents who required mechanical lift assistance were provided with adequate supervision and assistance to prevent accidents.