Failure to Follow Care Plan for Safe Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to safely transfer a resident using a full mechanical lift as required by the resident's care plan. The resident, who had diagnoses including congestive heart failure, morbid obesity, muscle weakness, and muscle wasting, was assessed as having no cognitive impairment and being dependent on staff for transfers. The care plan specified that transfers should be performed with a mechanical lift and two staff members. However, during an incident, the mechanical lift's battery died while transferring the resident, and staff proceeded to manually transfer the resident using a gait belt, with one staff member lifting under the resident's arms and another guiding the hips. The resident reported feeling unsafe and stated that she was told she needed the lift at all times for transfers. Staff interviews revealed inconsistent accounts regarding whether permission was obtained from the DON to perform the manual transfer, with one CNA stating that approval was given and another denying the DON's involvement. The DON confirmed that he was not present and had not authorized a change in the resident's transfer method, emphasizing that such changes require therapy evaluation or a physician's order. Facility policy required the use of mechanical lifting devices for high-risk residents except in emergencies, and backup batteries and additional lifts were available on each floor. Despite these policies and resources, the staff did not follow the resident's care plan or facility protocols during the transfer.