Mechanical Lift Transfer Performed by Single CNA
Penalty
Summary
A certified nursing assistant (CNA) transferred a male resident with a history of Wernicke's encephalopathy, generalized muscle weakness, muscle wasting, and a prior transient ischemic attack, using a mechanical lift without the required assistance of a second staff member. The resident's care plan and annual MDS assessment specified the need for a two-person physical assist for bed mobility and transfers, and facility policy mandated two staff for mechanical lift transfers. The CNA admitted to performing the transfer alone because no other staff were visible in the hallway and did not request assistance. Observation confirmed the resident was in his wheelchair with the mechanical lift sling still underneath him, and both the CNA and the resident stated the transfer was completed by one staff member. The resident reported feeling safe and noted that staff typically used two people for such transfers. The CNA had previously been trained and passed competency for two-person mechanical lift transfers. The facility's policy, effective at the time, required two staff for all mechanical lift transfers to ensure resident and staff safety.