Failure to Follow Care Plan for Mechanical Lift Transfers
Penalty
Summary
Staff failed to consistently implement and follow the care plan interventions for a resident who required the assistance of two staff members and a mechanical lift for all transfers. Despite the care plan and care card specifying the use of a Hoyer lift, two CNAs transferred the resident from bed to wheelchair without using the mechanical lift. The incident was directly observed by a nurse, and both CNAs acknowledged in their statements that they did not use the Hoyer lift, even though they were aware of the resident's transfer requirements. The resident involved had diagnoses including Alzheimer's disease, Major Depressive Disorder, and Anxiety Disorder, with moderate cognitive impairment and complete dependence on staff for care needs, positioning, transfers, and mobility. The failure to use the mechanical lift as specified in the care plan was confirmed through interviews, witness statements, and review of the resident's records, demonstrating a lack of adherence to established transfer protocols for this resident.