Failure to Secure Mechanical Lift Brakes During Resident Transfer
Penalty
Summary
Staff failed to provide adequate supervision and safe transfer assistance for a resident with significant physical and cognitive impairments. During a transfer from a wheelchair to a bed using a mechanical lift, two CNAs did not secure the brakes on the lift before elevating the resident. One CNA positioned the lift and began lifting the resident without locking the brakes, while the other CNA moved the wheelchair and assisted with the transfer. Both CNAs acknowledged after the transfer that the brakes had not been applied, and recognized that this was not in accordance with safe transfer procedures. The resident involved had a history of dementia, degenerative disease of the central nervous system, and complete trisomy 21 syndrome, and was dependent on staff for all mobility and transfers. The care plan indicated the resident was normally bedfast and required two staff for transfers using a mechanical lift. Interviews with the ADON and DON confirmed that staff are trained to apply the mechanical lift brakes before lifting a resident, and that failure to do so could result in injury. The facility was unable to provide a copy of its transfer and ADL policy when requested.