Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a Sara lift without the required second staff member. The resident, who had left hemiplegia and contracture of the left hand due to a stroke, was assessed as having very limited functional ability and required a two-person assist for all transfers. Despite this, the CNA performed the transfer alone, which was confirmed during interviews with the resident and the CNA. The resident reported feeling unsafe during the transfer and noted that only one person often assisted, even though two were required. Further review of the resident's clinical records, assessments, and care plan confirmed the need for a two-person assist due to the resident's physical limitations, including being tall, heavy, and non-ambulatory with no functionality on the left side. Both the physical and occupational therapists stated that a two-person assist was necessary for safety. Facility training records showed that the CNA had attended training on the proper use of mechanical lifts, and facility policy required adherence to manufacturer recommendations and assessment of the resident's condition to determine the appropriate level of assistance.