Failure to Lock Bed Brakes and Improper Mechanical Lift Use During Resident Transfers
Penalty
Summary
Staff failed to lock the brakes on a resident's bed while providing incontinence care and repositioning, resulting in the bed moving during the process. The resident, who had a history of left above-the-knee amputation, fracture, muscle weakness, morbid obesity, and anxiety disorder, was dependent on staff for transfers and had a documented risk for falls. During the observed care, the resident expressed concern about falling, and the Regional Nurse present confirmed that the bed brakes were not engaged and that the resident was positioned close to the edge of the bed. Additionally, staff did not operate a mechanical lift according to manufacturer instructions during transfers for two residents. In one instance, the sling strap was looped around the armrest of a wheelchair, requiring adjustment while the resident was suspended in the lift. The mechanical lift's leg bar was not spread as recommended by the manufacturer during the transfer, and the lift encountered obstacles under the bed. The staff involved did not demonstrate competency in the safe use of the mechanical lift, and the facility's policy lacked specific guidance on the correct positioning of the lift's leg bar during transfers. Interviews with facility leadership confirmed that staff were expected to follow manufacturer instructions for mechanical lifts, but there had been no recent competency audits or survey preparation related to transfers. The facility's observation form for lift/transfer safety did not include detailed steps for using mechanical lifts, and the relevant policies did not address the specific issues observed during the transfers.