Mechanical Lift Transfer Performed by Single Staff Member Resulted in Resident Injury
Penalty
Summary
A deficiency occurred when a nurse aide operated a mechanical sit-to-stand lift alone to transfer a resident diagnosed with chronic obstructive pulmonary disease. According to facility policy, at least two nursing staff are required to safely move a resident with a mechanical lift. The nurse aide transported the resident by herself into the bathroom, during which the resident's arm was bumped into the doorway. Documentation and staff interviews confirmed that the transfer was performed without the required second staff member present. The incident was discovered through a review of the resident's clinical record and an incident investigation report, which included statements from the involved staff. The administrator confirmed that the nurse aide was alone during the transfer and that the incident resulted in the resident's arm being injured when it was bumped on the door. The facility's policy and the events leading up to the incident were verified through interviews and documentation review.