Failure to Provide Required Two-Person Assist During Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was moderately cognitively impaired and dependent on staff for activities of daily living due to multiple sclerosis, paralytic syndrome, lack of coordination, and tremors, was transferred using a portable lift by a single certified nursing assistant (CNA) instead of the required two-person assist. Facility policy, as well as standard practice reported by multiple staff members, mandated that two staff members be present when using the lift for resident transfers. Despite this, the CNA proceeded alone because the resident was in a hurry to get up for a smoke break, resulting in the lift tilting and the resident being lowered to the floor. The incident was observed on camera, and the resident did not sustain injuries. Interviews with staff confirmed that the use of the lift by one person was a violation of both policy and standard procedure, and that adequate staffing was available at the time of the incident. The CNA involved acknowledged awareness of the policy but chose not to wait for assistance. The event was documented in a progress note, and the resident later confirmed the occurrence, stating they were not injured or afraid of the lift.