Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that residents who required mechanical lift transfers received adequate assistance and that proper procedures were followed to prevent accidents. For one resident with moderate cognitive impairment and physical limitations, two CNAs did not widen the base or lock the casters of the mechanical lift during a transfer from a wheelchair to a bed. The CNAs attached the sling and lifted the resident without maximizing the stability of the lift, and one CNA admitted uncertainty about whether she had widened the base, confirming that she did not lock the base at any point. Both CNAs acknowledged the importance of these safety steps and stated they had recently received training on proper transfer techniques. In another instance, a resident with severe cognitive impairment and decreased trunk control, who used a Geri-chair, was transferred by two CNAs using a mechanical lift. The operator positioned the lift in such a way that the base could not be widened to its maximum open position due to space constraints between the feet of the Geri-chair. The resident was lifted and moved to the bed, at which point the base was widened and locked before lowering the resident. The CNA stated she was aware of the need to widen the base for stability but was unable to do so because of the room layout. The assisting CNA described an alternative technique to allow for base widening but noted that staff had not been instructed on such methods during training. Interviews with the DON and ADM confirmed that staff are expected to always lock and widen the base of the mechanical lift during transfers to ensure safety and prevent movement or instability. Review of the mechanical lift manual also emphasized the necessity of having the legs in the maximum open position for stability and safety, and provided warnings about the risks of not following these procedures. The failure to consistently apply these safety measures during mechanical lift transfers constituted the identified deficiency.