Failure to Provide Adequate Supervision During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living due to diagnoses including dementia, Alzheimer's disease, diabetes, and a left hand contracture, was transferred using a mechanical lift by a single CNA, despite the care plan and facility policy requiring two staff for such transfers. The resident was non-ambulatory, used a wheelchair, and required total assistance for bathing and transfers. During a shower transfer, the CNA performed the mechanical lift transfer alone because other staff were unavailable to assist. Following the transfer, the resident was observed to have redness, clear discharge, and discoloration around the left eye, which was initially treated as an eye infection due to the resident's history of similar symptoms. However, further assessment revealed a bruise measuring 4.4 cm by 3.2 cm, and it was determined that the injury was caused when the resident's face was struck by the bar of the mechanical lift during the transfer. The CNA involved acknowledged being alone during the transfer and stated that she could not find another staff member to assist, as required by facility policy and training. Interviews with multiple staff members confirmed that all were trained to use two staff for mechanical lift transfers and were instructed not to perform such transfers alone. The incident was reported to administration and the state, and the facility's policy clearly stated that at least two nursing assistants are needed for safe mechanical lift transfers. The failure to follow this policy resulted in the resident sustaining a significant injury during the transfer.