Improper Use of Mechanical Lift as Transport Device Creates Immediate Jeopardy
Penalty
Summary
The facility failed to ensure the resident environment was as free from accident hazards as possible when two nurse aides prepared to use a total mechanical lift as a transport device for a resident after a shower. The resident was placed on a shower bed in the hallway outside her room, and one nurse aide began hooking the lift pad to the mechanical lift, intending to wheel the resident into her room while suspended in the lift. The surveyor intervened before the transfer could occur, after confirming with the nurse aide that this was his usual practice due to space constraints in the room. The resident's room was crowded with her bed, her roommate's bed, a fall mat, an over-bed table, and two wheelchairs, making maneuvering difficult. The Invacare Reliant 450 lift manual and warning labels clearly state that the lift is not intended as a transport device and should only be used to transfer individuals from one resting surface to another, not for moving them across distances or over uneven surfaces. Despite these instructions, the nurse aide attempted to use the lift inappropriately, which was only prevented by the surveyor's intervention. The incident was determined to have placed the resident in an immediate jeopardy situation due to the risk associated with improper use of the mechanical lift.