Improper Transfer Method Used Due to Equipment Failure
Penalty
Summary
A deficiency occurred when a resident, who is cognitively intact and dependent on staff for transfers due to a right femur fracture, was transferred using a sit-to-stand mechanical lift instead of the care plan-specified full mechanical lift. On the day in question, the full mechanical lift on the resident's hallway was not functioning, and maintenance staff were unavailable. The Certified Nursing Assistant (CNA) used the sit-to-stand lift to transfer the resident from the wheelchair to the bed, despite the resident expressing concern about falling. The resident's care plan and Minimum Data Set (MDS) indicated that a full mechanical lift was required for transfers, and there had been no documented change in transfer status from therapy staff. Interviews with facility staff confirmed that the resident's transfer status remained unchanged and that the use of the sit-to-stand lift was not approved for this resident. The CNA acknowledged submitting a work order for the broken lift but proceeded with the alternative transfer method without updated recommendations from therapy or changes to the care plan. The facility's policy requires ongoing assessment and documentation of transfer needs, which was not followed in this instance.