Improper Use of Mechanical Lifts and Wheelchairs During Resident Transfers
Penalty
Summary
Surveyors identified multiple deficiencies related to the improper use of mechanical lifts and wheelchairs during resident transfers. In several observed instances, staff failed to follow manufacturer instructions and facility protocols for safe transfer practices. For example, staff did not consistently lock wheelchair wheels during transfers, and mechanical lift wheels were sometimes locked or unlocked contrary to manufacturer recommendations. In one case, staff raised a resident from a toilet using a sit-to-stand lift without locking the lift's wheels, and staff provided conflicting statements about the correct procedure. Manufacturer documentation specified that the sit-to-stand lift's wheels should be unlocked after the resident is raised, but staff were inconsistent in their application of this guidance. Additionally, staff failed to ensure that wheelchair foot pedals were attached while transporting a resident who was unable to self-propel, and a staff member acknowledged that foot pedals should be used when pushing a resident in a wheelchair. Another observation revealed that a resident was transferred using a total body mechanical lift with the legs closed and the wheelchair unlocked, contrary to manufacturer instructions that require the legs to be open for stability and the wheelchair to be locked during transfer. Staff interviews confirmed a lack of consistent understanding and application of these safety procedures. The residents involved had significant cognitive and physical impairments, including severe dementia, end-stage renal disease, history of stroke, and incontinence, requiring varying levels of assistance with activities of daily living and mobility. Care plans specified the need for mechanical lifts, transfer discs, and assistance from multiple staff members, yet these plans were not always followed as observed. The facility also lacked a policy regarding wheelchair safety, as confirmed by the administrator, contributing to inconsistent practices among staff.