Failure to Provide Required Assistance During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) used a full body mechanical lift to transfer a resident with severe cognitive impairment and total dependence for mobility without the required assistance of a second staff member. The resident, who had diagnoses including non-traumatic brain dysfunction and Alzheimer's disease, was transferred to bed and later from bed to a wheelchair by the CNA alone, despite facility policy mandating two staff for such transfers. During one of these transfers, the lift became entangled with a bed cord, causing the CNA to pull the lift away forcefully, which resulted in the lift bar spinning unexpectedly. Subsequently, the resident was observed by a registered nurse to have sustained a purple bruise around the left eye and a small cut over the bridge of the nose with dried blood. The CNA denied knowledge of how the injury occurred. The facility's policy, which was in effect at the time, clearly required at least two nursing assistants to safely operate a mechanical lift for resident transfers, and staff were available to assist if requested.