Failure to Ensure Proper Footwear During Mechanical Lift Transfer
Penalty
Summary
Staff failed to ensure that a resident with diabetes and a history of stroke wore proper footwear during a mechanical lift transfer. The resident, who had moderate cognitive impairment and was at risk for foot injury and falls, was observed being transferred with a sit-to-stand lift by two CNAs while wearing non-gripper socks. After the transfer, staff assisted the resident in putting on shoes and wheelchair pedals. Facility policy required the use of appropriate techniques and devices to ensure resident safety during transfers, including the use of non-skid footwear as outlined in both the facility's Safe Lifting and Movement of Residents policy and external nursing assistant guidelines. The DON confirmed that the resident should have worn shoes or gripper socks during the transfer, in accordance with these policies.