Failure to Use Required Mechanical Lifts for Dependent Residents
Penalty
Summary
The facility failed to ensure that three residents who required a full mechanical lift for transfers were consistently transferred using the appropriate equipment, as specified in their care plans and facility policy. Observations, interviews, and record reviews revealed that these residents were either manually transferred by staff or transferred using alternative equipment, such as a sit-to-stand lift, instead of the required full mechanical lift. Staff reported that on at least one occasion, a resident was manually transferred by two CNAs because there were no clean slings available for the mechanical lift, and the resident did not have a sling under her, making the lift unusable at the time of transfer. The care plans and Kardex sheets for the three residents clearly documented the need for a full body mechanical lift for all transfers. Despite this, staff interviews indicated a lack of consistent adherence to these documented requirements. Some CNAs stated they relied on verbal instructions from therapy staff or other CNAs rather than the written care plans or Kardex, leading to confusion and inconsistent transfer practices. Additionally, there was a lack of communication among staff regarding changes in transfer status, with some staff unaware of where to find the correct information in the electronic charting system. The residents involved had significant medical conditions affecting their mobility, including dementia, muscle wasting, orthopedic issues, and hereditary spastic paraplegia. All were dependent on staff for transfers and used wheelchairs for mobility. At the time of the deficiency, observations confirmed that these residents did not have full mechanical lift slings under them, and staff acknowledged using manual or alternative transfer methods contrary to the care plan. The facility's own investigation confirmed that the failure to use the mechanical lift as required was due to a lack of proper equipment setup and communication lapses among staff.