Failure to Follow Two-Staff Protocol During Mechanical Lift Transfer
Penalty
Summary
Facility staff failed to follow professional standards of quality by not ensuring that two trained staff members assisted with mechanical lift transfers for a resident. The resident, who had multiple diagnoses including chronic kidney disease, diabetes with kidney complications, hemiplegia, and muscle weakness, was cognitively moderately impaired according to a recent MDS assessment. During an incident, the resident was being transferred with a Hoyer lift by a single CNA, contrary to facility policy and best practice, which require two trained staff for such transfers. The resident reported being struck in the head by the Hoyer lift bar during the transfer, resulting in a small hematoma. Interviews with the resident, CNA, and DON confirmed that only one staff member was present during the transfer and that the incident occurred when the lift became unstable. The CNA acknowledged that standard protocol requires two staff for mechanical lift transfers and that she had called for help but proceeded alone when no one responded. Facility policy, as well as external best practice guidelines, specify the need for two trained staff to ensure safe operation and positioning during mechanical lift use. The facility leadership confirmed the policy and had no additional information to provide regarding the incident.