Failure to Follow Care Plan and Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, dementia, paraplegia, and other significant medical conditions experienced a fall while being transferred using a sit-to-stand lift. The resident's care plan and CNA Kardex both specified that transfers required the use of a sit-to-stand lift with assistance from two staff members. However, on the evening of the incident, only one CNA was present during the transfer. The resident slipped out of the sling, fell, struck the back of her head, and briefly lost consciousness, resulting in a laceration that required two staples. The investigation revealed that the CNA performing the transfer was not aware that two staff were required for the procedure, despite this being documented in the care plan and Kardex. The CNA also did not recall if the transfer required one or two staff or what sling size was needed. Interviews with other staff indicated that sling sizes were not documented on the Kardex or care plan, and slings were not labeled for individual residents. There was also no evidence of recent training for staff on determining sling size, proper sling attachment, or safe transfer procedures prior to the incident. The facility's investigation into the incident did not address whether the correct sling size was used, if the sling was properly attached, or if the CNA had adequate knowledge of the transfer requirements. The root cause analysis focused on the resident's underlying diagnoses and loss of balance, but did not fully explore staff compliance with the care plan or equipment use. The surveyor noted that the care plan was not followed, as only one staff member assisted with the transfer, directly contributing to the resident's fall and injury.