Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfers
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including cerebrovascular accident and dementia, was not provided adequate supervision and assistance during transfers and toileting. The resident required total staff assistance for activities of daily living, including transfers and toileting, as documented in the care plan, which specified the use of a dependent non-weight bearing mechanical lift with two staff members present. Despite these requirements, a single Certified Nurse Assistant (CNA) performed three separate movements using the mechanical lift without the assistance of a second staff member. During observation, the CNA completed the transfer and toileting tasks alone, including moving the resident from a recliner to a wash basin, then to a wheelchair, using the mechanical lift. Staff interviews confirmed that the expectation and facility policy required two staff to be present and engaged when operating the mechanical lift for dependent residents. The CNA acknowledged performing the tasks alone and stated this was the usual practice for this resident, despite the care plan and facility policy. Further interviews with other staff, including CNAs, the Clinical Care Coordinator, the Director of Nursing (DON), and the Administrator, all confirmed that two staff should be present for such transfers to ensure safety. The facility's Safe Resident Handling Program also outlined the need for a 'TIME OUT' safety stop and two staff for full weight-bearing support with the total lift. The failure to follow these protocols resulted in the resident not being adequately protected from possible accidents and injury during transfers.