Failure to Implement Safety Interventions and Staff Training During Mechanical Lift Transfer
Penalty
Summary
The facility failed to implement appropriate safety interventions and staff training to prevent an avoidable fall for a resident who was dependent on staff for activities of daily living and had multiple medical diagnoses, including respiratory failure and diabetes. The resident, who had intact cognition, was being transferred from bed to a shower chair using a mechanical lift by two nursing assistants. During the transfer, the mechanical lift tipped over, causing the resident to fall onto the shower chair, resulting in pain to the right shoulder and neck. The incident investigation revealed that the mechanical lift tipped due to improper use, specifically the likely failure to properly extend the stabilizing legs, which, combined with the resident's weight, caused the center of gravity to shift. Staff interviews indicated that although one staff member reported having received training on the mechanical lift, the facility was unable to locate documentation of this training for the staff involved. The maintenance director confirmed that monthly preventative maintenance was performed on all mechanical lifts and found no defects with the equipment after the incident. The facility's policy required staff to be trained on the use of assistive devices and transfer equipment, but this was not verified for all staff involved in the incident.