Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
Facility staff failed to provide the required two-person assistance during a mechanical lift transfer for a resident with multiple medical conditions, including chronic kidney disease, diabetes with kidney complications, hemiplegia, and muscle weakness. The resident, who had moderately impaired cognitive abilities, was being transferred by a CNA using a Hoyer lift when the lift's leg became caught on a roommate's bed, causing the lift to tip. During this incident, the resident was struck on the head by the Hoyer lift sling bar, resulting in a small hematoma. The CNA admitted to performing the transfer alone after calling for help and receiving no response, despite facility policy requiring two trained staff for such transfers. Interviews with staff confirmed that only one CNA was present during the transfer, and both the DON and other nursing staff acknowledged that this was not in accordance with standard protocol. Documentation in the clinical record and facility forms corroborated the resident's report of being hit in the head and the subsequent development of a hematoma. The incident was further substantiated by medical notes and an emergency department evaluation, which found no acute injuries but confirmed the occurrence of head trauma. The facility's mechanical lift policy explicitly states that two trained staff must assist with mechanical lift transfers, which was not followed in this case.