Failure to Provide Adequate Supervision and Equipment Safety During Lift Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and safe practices during resident transfers using mechanical lifts, resulting in falls and injuries to two residents. In one incident, a resident with severe cognitive impairment and dependent on staff for transfers fell when the sling detached from the lift during a transfer, with only one staff member present instead of the required two. The resident suffered a rib fracture as a result of the fall. Documentation and interviews confirmed that the lift was not properly hooked and that only one staff member was assisting at the time. In a separate incident, another resident with severe cognitive impairment and also dependent on a lift for transfers sustained a fracture to the left arm and hip when a sling strap broke during a transfer. The resident reported feeling safe until the strap broke, which they described as a freak accident. Both incidents involved residents who required full assistance for transfers and had significant cognitive impairments, highlighting lapses in supervision and equipment safety during lift transfers.